Middle Range Or Interdisciplinary Theory Evaluation 1
Table of Contents
Middle Range Or Interdisciplinary Theory
Assignment 2: Middle Range or Interdisciplinary Theory Evaluation
As addressed this week, middle range theories are frequently used as a framework for exploring nursing practice problems. In addition, theories from other sciences, such as sociology and environmental science, have relevance for nursing practice. For the next few weeks you will explore the use of interdisciplinary theories in nursing.
This Assignment asks you to evaluate two middle range or interdisciplinary theories and apply those theories to a clinical practice problem. You will also create a hypothesis based upon each theory for an evidence-based practice project to resolve a clinical problem.
Note: This Assignment will serve as your Major Assessment for this course.
To prepare:
- Review strategies for evaluating theory presented by Fawcett and Garity in this week’s Learning Resources (see under list of Required Readings and attached pdf file)
- Select a clinical practice problem that can be addressed through an evidence-based practice project. Note: You may continue to use the same practice problem you have been addressing in earlier Discussions and in Week 7 Assignment 1.
- Consider the middle range theories presented this week, and determine if one of those theories could provide a framework for exploring your clinical practice problem. If one or two middle range theories seem appropriate, begin evaluating the theory from the context of your practice problem.
- Formulate a preliminary clinical/practice research question that addresses your practice problem. If appropriate, you may use the same research question you formulated for Assignment #4.
Write a 10- to 12-page paper (including references) in APA format and a minimum of 8 references or more, using material presented in the list of required readings to consider interdisciplinary theories that may be appropriate for exploring your practice problem and research question (refer to the sample paper attached as “Assignment example”). Include the level one headings as numbered below:
1) Introduction with a purpose statement (e.g. The purpose of this paper is…)
2) Briefly describe your selected clinical practice problem.
3) Summarize the two selected theories. Both may be middle range theories or interdisciplinary theories, or you may select one from each category.
4) Evaluate both theories using the evaluation criteria provided in the Learning Resources.
5) Determine which theory is most appropriate for addressing your clinical practice problem. Summarize why you selected the theory. Using the propositions of that theory, refine your clinical / practice research question.
6) conclusion
MY PRACTICE PROBLEM IS AS FOLLOWED:
P: Patients suffering from Type 2 Diabetes Mellitus
I: Who are involved in diabetic self-care programs
C: Compared to those who do not participate in self-care programs
O: Are more likely to achieve improved glycemic control
THE THEORIES USED FOR THIS MODEL ARE:
Dorothea Orem Self-Care Theory and The Self-Efficacity in nursing Theory by Lenz & Shortridge-Baggett, or the Health Promotion Model by Pender, Murdaugh & Parson (Pick 2)
Required Readings
McEwin, M., & Wills, E.M. (2014). Theoretical basis for nursing. (4th ed.). Philadelphia, PA: Wolters Kluwer Health.
- Chapter 10, “Introduction to Middle Range Nursing Theories”
Chapter 10 begins the exploration of middle range theories and discusses their development, refinement, and use in research.
- Chapter 11, “Overview of Selected Middle Range Nursing Theories”
Chapter 11 continues the examination of middle range theories and provides an in-depth examination of a select set of theories
· Chapter 15, “Theories from the Biomedical Sciences”
Chapter 15 highlights some of the most commonly used theories and principles from the biomedical sciences and illustrates how they are applied to studies conducted by nurses and in nursing practice.
· Chapter 16, “Theories, Models, and Frameworks from Administration and Management”
Chapter 16 presents leadership and management theories utilized in advanced nursing practice.
· Chapter 18, “Application of Theory in Nursing Practice”
Chapter 18 examines the relationship between theory and nursing practice. It discusses how evidence-based practice provides an opportunity to utilize research and theory to improve patient outcomes, health care, and nursing practice.
Gray, J.R., Grove, S.K., & Sutherland, S. (2017). Burns and Grove’s the practice of nursing research: Appraisal, synthesis, and generation of evidence (8th ed.). St. Louis, MO: Saunders Elsevier.
- Chapter 6, “Objectives, Questions, Variables, and Hypotheses”
Chapter 6 guides nurses through the process of identifying research objectives, developing research questions, and creating research hypotheses.
· Review Chapter 2, “Evolution of Research in Building Evidence-Based Nursing Practice”
· Chapter 19, “Evidence Synthesis and Strategies for Evidence-Based Practice”
This section of Chapter 19 examines the implementation of the best research evidence to practice.
Fawcett, J., & Garity, J. (2009). Chapter 6: Evaluation of middle-range theories. Evaluating Research for Evidence-Based Nursing. Philadelphia, Pennsylvania: F. A. Davis.
Note: You will access this article from the Walden Library databases.
This book chapter evaluates the use and significance of middle-range theories in nursing research and clinical practice.
DeSanto-Madeya, S., & Fawcett, J. (2009). Toward Understanding and Measuring Adaptation Level in the Context of the Roy Adaptation Model. Nursing Science Quarterly, 22(4), 355–359.
Note: You will access this article from the Walden Library databases.
This article describes how the Roy Adaptation Model (RAM) is used to guide nursing practice, research, and education in many different countries.
Jacelon, C., Furman, E., Rea, A., Macdonald, B., & Donoghue, L. (2011). Creating a professional practice model for postacute care: Adapting the Chronic Care Model for long-term care. Journal of Gerontological Nursing, 37(3), 53–60.
Note: You will access this article from the Walden Library databases.
This article addresses the need to redesign health care delivery to better meet the needs of individuals with chronic illness and health problems.
Murrock, C. J., & Higgins, P. A. (2009). The theory of music, mood and movement to improve health outcomes. Journal of Advanced Nursing, 65 (10), 2249–2257. doi:10.1111/j.1365-2648.2009.05108.x
Note: You will access this article from the Walden Library databases.
This article discusses the development of a middle-range nursing theory on the effects of music on physical activity and improved health outcomes.
Amella, E. J., & Aselage, M. B. (2010). An evolutionary analysis of mealtime difficulties in older adults with dementia. Journal of Clinical Nursing, 19(1/2), 33–41. doi:10.1111/j.1365-2702.2009.02969.x
Note: You will access this article from the Walden Library databases.
This article presents findings from a meta-analysis of 48 research studies that examined mealtime difficulties in older adults with dementia.
Frazier, L., Wung, S., Sparks, E., & Eastwood, C. (2009). Cardiovascular nursing on human genomics: What do cardiovascular nurses need to know about congestive heart failure? Progress in Cardiovascular Nursing, 24(3), 80–85.
Note: You will access this article from the Walden Library databases.
This article discusses current genetics research on the main causes of heart failure.
Mahon, S. M. (2009). Cancer Genomics: Cancer genomics: Advocating for competent care for families. Clinical Journal of Oncology Nursing, 13(4), 373–3 76.
Note: You will access this article from the Walden Library databases.
This article advocates for nurses to stay abreast of the rapid changes in cancer prevention research and its application to clinical practice.
Mayer, K. H., Venkatesh, K. K. (2010). Antiretroviral therapy as HIV prevention: Status and prospects. American Journal of Public Health, 100(10), 1867–1 876. doi: 10.2105/AJPH.2009.184796
Note: You will access this article from the Walden Library databases.
This article provides an in-depth examination of potential HIV transmission prevention.
Pestka, E. L., Burbank, K. F., & Junglen, L. M. (2010). Improving nursing practice with genomics. Nursing Management, 41(3), 40–44. doi: 10.1097/01.NUMA.0000369499.99852.c3
Note: You will access this article from the Walden Library databases.
This article provides an overview of genomics and how nurses can apply it in practice.
Yao, L., & Algase, D. (2008). Emotional intervention strategies for dementia-related behavior: A theory synthesis. The Journal of Neuroscience Nursing, 40(2), 106–115.
Note: You will access this article from the Walden Library databases.
This article discusses a new model that was developed from empirical and theoretical evidence to examine intervention strategies for patients with dementia.
Fineout-Overholt, E., Williamson, K., Gallagher-Ford, L., Melnyk, B., & Stillwell, S. (2011). Following the evidence: Planning for sustainable change. The American Journal Of Nursing, 111(1), 54–60.
This article outlines the efforts made as a result of evidence-based practice to develop rapid response teams and reduce unplanned ICU admissions.
Kleinpell, R. (2010). Evidence-based review and discussion points. American Journal of Critical Care, 19(6), 530–531.
This report provides a review of an evidence-based study conducted on patients with aneurismal subarachnoid hemorrhage and analyzes the validity and quality of the research.
Koh, H. (2010). A 2020 vision for healthy people. The New England Journal Of Medicine, 362(18), 1653–1656.
This article identifies emerging public health priorities and helps to align health-promotion resources, strategies, and research.
Moore, Z. (2010). Bridging the theory-practice gap in pressure ulcer prevention. British Journal of Nursing, 19(15), S15–S18.
This article discusses the largely preventable problem of pressure ulcers and the importance of nurses being well-informed of current prevention strategies.
Musker, K. (2011). Nursing theory-based independent nursing practice: A personal experience of closing the theory-practice gap. Advances In Nursing Science, 34(1), 67–77.
This article discusses how personal and professional knowledge can be used in concert with health theories to positively influence nursing practice.
Roby, D., Kominski, G., & Pourat, N. (2008). Assessing the barriers to engaging challenging populations in disease management programs: The Medicaid experience. Disease Management & Health Outcomes, 16(6), 421–428.
This article explores the barriers associated with chronic illness care and other factors faced by disease management programs for Medicaid populations.
Sobczak, J. (2009). Managing high-acuity-depressed adults in primary care. Journal of the American Academy of Nurse Practitioners, 21(7), 362–370. doi: 10.1111/j.1745-7599.2009.00422.x
This article discusses a method found which positively impacts patient outcomes used with highly-acuity-depressed patients.
Thorne, S. (2009). The role of qualitative research within an evidence-based context: Can metasynthesis be the answer? International Journal of Nursing Studies, 46(4), 569–575. doi: 10.1016/j.ijnurstu.2008.05.001
The article explores the use of qualitative research methodology with the current evidence-based practice movement.
Optional Resources
McCurry, M., Revell, S., & Roy, S. (2010). Knowledge for the good of the individual and society: Linking philosophy, disciplinary goals, theory, and practice. Nursing Philosophy, 11(1), 42–52.
Calzone, K. A., Cashion, A., Feetham, S., Jenkins, J., Prows, C. A., Williams, J. K., & Wung, S. (2010). Nurses transforming health care using genetics and genomics. Nursing Outlook, 58(1), 26–35. doi: 10.1016/j.outlook.2009.05.001
McCurry, M., Revell, S., & Roy, S. (2010). Knowledge for the good of the individual and society: Linking philosophy, disciplinary goals, theory, and practice. Nursing Philosophy, 11(1), 42–52.
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This chapter focuses on the theory (T) component of conceptual-theoretical-empirical (C-T-E) structures for research.
Chapter 6
Evaluation of Middle-Range Theories
KEYWORDS
Axiom
Deductive Reasoning
Explicit Middle-Range Theory
Hypothesis
Implicit Middle-Range Theory
Inductive Reasoning
Internal Consistency
Middle-Range Theory
Parsimony
Postulate
Premise
Reasoning
Semantic Clarity
Semantic Consistency
Significance
Social Significance
Structural Consistency
Testability
Theorem
Theoretical Significance
Recall from Chapter 2 that the T component of a C-T-E structure is the middle-range theory that was generated or tested by research. In that chapter, we defined a theory as a set of relatively concrete and specific concepts and propositions that are derived from the concepts and propositions of a conceptual model. We also pointed out that a middle-range theory guides research by providing the focus for the specific aims for the research. In Chapter 3 you began to learn where to look for information about the middle-range theory in research reports (Box 6–1) and what information you could expect to find (Box 6–2).
BOX 6-1
Evaluation of Middle-Range Theories: Where Is the Information?
Content about the middle-range theory may be found in every section of the research report.
BOX 6-2
Evaluation of Middle-Range Theories: What Is the Information?
The name of the middle-range theory
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In Chapter 4, you began to learn how to determine how good the available information about the theory is. More specifically, in Chapter 4 we presented a framework for evaluation of the different components of C-T-E structures for theory-generating research and theory- testing research.
In this chapter, you will learn more about what middle-range theories are and how to evaluate them to determine how good the information about the T component for theory-generating research and theory-testing research is. After explaining how to identify a middle-range theory, we discuss in detail the four criteria in the framework identified in Chapter 4 for evaluating the T component of C-T-E structures—significance, internal consistency, parsimony, and testability— and provide examples that should help you better understand how to apply the criteria as you read research reports. Application of the criteria will facilitate your evaluation of how good the informa- tion about the middle-range theory provided in the research report is.
HOW IS THE MIDDLE-RANGE THEORY IDENTIFIED?
We believe that generating or testing a middle-range theory is the main reason for research. Consequently, a vast number of middle-range theories exist. Sometimes, the name of the middle-range theory is stated explicitly in the research report, but sometimes the middle-range theory is not stated explicitly and is only implied.
Explicit Middle-Range Theories
A review of research guided by seven different nursing conceptual models yielded more than 50 explicitly named middle-range theories that were directly derived from the conceptual models. The theories and the conceptual models from which they were derived are listed in Table 6–1 on the CD that comes with this book.
The conceptual frames of reference for three other explicit middle-range nursing theories were extracted from publications about the theories (Fawcett, 2005b). Although none of the theories were derived from a nursing conceptual model, statements reflecting some of the nursing metaparadigm concepts—human beings, environment, health, and nursing—were identified. The theories and relevant citations are:
1. Orlando’s Theory of the Deliberative Nursing Process (Orlando, 1961; Schmieding, 2006)
2. Peplau’s Theory of Interpersonal Relations (Peplau, 1952, 1997) 3. Watson’s Theory of Human Caring (Watson, 1985, 2006)
The conceptual origins of many other explicitly named middle-range nursing theories are not yet clear; examples are listed in Table 6–2, which is included on the CD that comes with this book. Some explicitly named middle-range theories that are tested by nurse researchers come from other disciplines; examples are given in Table 6–3 on the CD. Additional information about the theories listed in Tables 6–2 and 6–3 can be found in Marriner Tomey and Alligood (2006), Peterson and Bredow (2004), Smith and Liehr (2003), and/or Ziegler (2005).
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Although the conceptual frame of reference for the theories listed in Table 6–3 typically is not mentioned in the published research report, one such theory—the Theory of Planned Behavior (TPB)—was linked with Neuman’s Systems Model and with Orem’s Self-Care Framework by Villarruel and her colleagues (2001). They explained that the linkage placed the TPB within a nursing context and provided direction for a program of nursing research that could progress from “an explanation of the antecedents of behavioral actions to a prediction of the effects of nursing interventions on behavioral actions that are directed toward health promotion and dis- ease prevention” (p. 160). They also explained that linkage of the TPB to a nursing conceptual model is needed if effects of interventions are to be studied, because interventions are not part of the TPB.
Implicit Middle-Range Theories
When the middle-range theory is implicit—that is, when it is not explicitly named—you may want to make up a name to increase your understanding of the theory. Finding the information
Chapter 6 ■ Evaluation of Middle-Range Theories 75
BOX 6-3
Naming an Implicit Middle-Range Theory
Example from a Theory-Generating Research Report
Study purpose
The purpose of this descriptive study was to identify patients’ perceptions of fatigue during chemotherapy for Hodgkin’s disease.
Results
Analysis of the patients’ responses to an open-ended questionnaire revealed three categories of fatigue—exhausted, sleepy, and tired.
Possible names for the middle-range theory
• Perceptions of Fatigue Theory
• Theory of Categories of Chemotherapy Fatigue
Example from a Theory-Testing Research Report
Study purpose
The purpose of this experimental study was to determine the effect of exercise on chemotherapy- related fatigue.
Hypothesis
An increase in exercise will decrease chemotherapy-related fatigue.
Possible names for the middle-range theory
• Theory of the Effects of Exercise on Fatigue
• Exercise and Fatigue Theory
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in a research report that may be used to identify a name for the theory can be challenging or even frustrating. Sometimes, the statement of the study purpose or aims can be used as the basis for the name of the theory. Or, you may have to rely on the categories or themes and their defini- tions in reports of theory-generating research and the study variables, definitions of variables, and hypotheses in reports of theory-testing research. Examples from fictitious studies are given in Box 6–3. (Recall that we discussed categories, themes, variables, definitions, and hypotheses in Chapter 2, and we identified where to look for the content of the T compo- nent in Chapters 3 and 4.)
HOW IS THE CRITERION OF SIGNIFICANCE OF A MIDDLE-RANGE THEORY APPLIED?
The criterion of significance of a middle-range theory draws attention to the importance of the theory to society and to the advancement of knowledge within a discipline. We call the importance of the theory to society its social significance, and the importance of the theory to advancement of knowledge its theoretical significance.
Application of the criterion of significance helps you determine whether enough informa- tion about social significance and theoretical significance is given in the research report. Enough information means that you can understand just how important the theory is to society and how the theory has filled a gap in or extended existing knowledge. The same amount of infor- mation about social significance and theoretical significance should be included in reports of both theory-generating research and theory-testing research.
The criterion of significance is met when you can answer yes to two questions:
• Is the middle-range theory socially significant? • Is the middle-range theory theoretically significant?
Is the Middle-Range Theory Socially Significant?
The criterion of significance requires the middle-range theory to be socially significant. That means the theory is about people experiencing a health condition that currently is regarded as having some practical importance by the general public and members of one or more dis- ciplines. The social significance of a middle-range theory is obvious when the theory focuses on a health condition, such as cancer, heart disease, or diabetes, that is experienced by a rel- atively large number of people. Social significance is also obvious when the theory focuses on a health condition that is experienced by a relatively small number of people but has a large impact on the quality of people’s lives, such as spinal cord injury or mental illness. In other words, social significance is concerned with whether the health condition experienced by people is regarded as having a considerable actual or potential impact on desired lifestyle. The social significance of a middle-range theory typically is explained in a few sentences about the incidence of a particular health condition (Cowen, 2005). An example of social significance from Newman’s (2005) study of correlates of functional status of caregivers of children in body casts is given in Box 6–4.
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Is the Middle-Range Theory Theoretically Significant?
The criterion of significance also requires the middle-range theory to be theoretically signif- icant. That means the theory offers new insights into the experiences of people who have a certain health condition. The theoretical significance of a nursing theory typically is explained in a concise summary of “what is known, what is not known, and how the results from [the research] advance . . . knowledge” (Cowen, 2005, p. 298). In other words, the information given in the research report about theoretical significance should tell you that the research focuses on the next meaningful step in the development of a theory about people with a certain health condition. Sometimes, a researcher will write that the research was conducted because nothing was known about the research topic. Such a statement does not meet the criterion of significance because it is possible that the topic is trivial and, there- fore, the research is trivial. An example of an explanation of theoretical significance from Newman’s study of correlates of functional status of caregivers of children in body casts is given in Box 6–5.
Chapter 6 ■ Evaluation of Middle-Range Theories 77
BOX 6-4
Example of Statement of Social Significance
The number of children who are placed in body casts each year is unknown. Observations in orthopedic clinics, however, indicate that a relatively small number of children are so treated. Mothers, fathers, and others who care for children in body casts face challenges that disrupt their usual pattern of daily living (Newman, 2005, p. 416).
(In this example, although a large number of children do not have a health condition requir- ing a body cast, their caregivers face considerable challenges.)
BOX 6-5
Example of Statement of Theoretical Significance
Developmental needs of the child, specific care requirements related to the body cast, and changes in parental functional status, health, psychological feelings, and family needs comprise typical challenges that must be faced by caregivers (Newman, 1997b; Newman & Fawcett, 1995). Previous studies of functional status during normal life transitions and serious illness have revealed that alterations in performance of usual role activities are influenced by demographic, health, psychological, and family variables (Tulman & Fawcett, 1996, 2003). This pilot study extended the investigation of correlates of functional status by examining the relation of personal health and self-esteem to functional status of caregivers of children in body casts [from] birth up to 3 years of age and [from] 3 to 12 years of age. The pilot study also provided data to determine the feasibility of a large-scale study. The long-term goal of the research is to assist caregivers to attain optimal functional status while caring for children in body casts (Newman, 2005, p. 416).
(In this example, the first two sentences tell you what is already known and include citations to previous research. The remaining three sentences tell you how the study extends knowledge, why it was conducted, and the long-term goal of the research.)
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BOX 6-6
Example of Semantic Clarity of a Middle-Range Theory Concept
• Concept: Self-esteem
• Constitutive definition: Self-esteem “is defined as the caregiver’s feelings of personal worth and value” (Newman, 2005, p. 417).
• Operational definition: Self-esteem was measured by Rosenberg’s Self-Esteem Scale (Newman, 2005).
HOW IS THE CRITERION OF INTERNAL CONSISTENCY OF A MIDDLE-RANGE THEORY APPLIED?
Internal consistency draws attention to the comprehensibility of the middle-range theory. Application of the criterion of internal consistency helps determine whether enough information about the theory concepts and propositions is given in the research report. Enough informa- tion means that you can identify each concept and how the concepts are described and linked. The same amount of information about internal consistency should be included in reports of both theory-generating research and theory-testing research.
The criterion of internal consistency is met when you can answer yes to three questions:
• Is each concept of the middle-range theory explicitly identified and clearly defined? • Are the same term and same definition used consistently for each concept? • Are the propositions of the middle-range theory reasonable?
Is Each Middle-Range Theory Concept Explicitly Identified and Clearly Defined?
The criterion of internal consistency requires every concept of the theory to be explicitly iden- tified and clearly defined. This requirement, which is called semantic clarity (Chinn & Kramer, 2004; Fawcett, 1999), is met when each concept can be identified and both theoret- ical and operational definitions for each concept are included in the research report. An exam- ple from Newman’s (2005) study of correlates of functional status of caregivers of children in body casts is given in Box 6–6. (Recall from Chapter 2 that a constitutive definition provides meaning for a concept, and an operational definition indicates how the concept was measured.)
Semantic clarity requires that even concepts that are generally understood in everyday language must be clearly defined when used in theories. As Chinn and Kramer (2004) pointed out,
Words like stress and coping have general common language meanings, and they also have specific theoretic meanings. . . . If words with multiple meanings are used in the- ory and not defined, a person’s everyday meaning of the term, rather than what is meant in the theory, often is assumed; therefore, clarity is lost. (p. 110)
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Are the Same Term and Same Definition Used Consistently for Each Middle-Range Theory Concept?
Semantic clarity is enhanced when the same term and same constitutive definition are used for each concept throughout the research report. The requirement for use of the same term and same constitutive definition is called semantic consistency (Chinn & Kramer, 2004; Fawcett, 1999). Although requiring use of the same term for the same concept may seem obvious, some- times a researcher uses different labels for the same concept. For example, a researcher may reduce clarity by referring to both self-esteem and self-confidence in the same research report, although the theory focuses only on self-esteem. Chinn and Kramer (2004) explained,
Normally, varying words to represent similar meanings is a writing skill that can be used to avoid overuse of a single term. But, in theory, if several similar concepts are used interchangeably when one would suffice, . . . the clarity of the [concept] is reduced rather than improved. (p. 110)
A researcher also may reduce clarity by using different constitutive definitions for the same concept. For example, if self-esteem is defined as “feelings of personal worth and value,” that concept should not also be defined as “feelings of self-confidence” in the same research report. Different definitions of the same concept that are explicit are, as Chinn and Kramer (2004) noted, “fairly easy to uncover” (p. 111). In contrast, when a different definition is not explicit but only implied, the inconsistency may be more difficult to identify. Suppose, for example, that a researcher explicitly defined self-esteem as “feelings of personal worth and value” and then wrote about caregivers’ feeling self-confident when bathing a child in a body cast. It would be difficult to know whether the researcher was referring to the caregivers’ self- esteem or another concept when discussing feelings of self-confidence.
Sometimes a researcher may use more than one operational definition for the same concept. If all of the operational definitions identify instruments that measure the same constitutive def- inition of the concept, the requirement of semantic consistency is met. For example, using the constitutive definition given in Box 6–6, a researcher might operationally define self-esteem as measured by both Rosenberg’s Self-Esteem Scale and a Personal Worth and Value Questionnaire that asks caregivers to rate their feelings of personal worth and value on a scale of 1 to 10, with 1 equivalent to feelings of very low personal worth and value and 10 equiva- lent to feelings of very high personal worth and value.
However, if the instruments identified in the operational definitions measure different constitutive definitions of the concept, the requirement of semantic consistency is not met. For example, again using the constitutive definition of self-esteem given in Box 6–6, a researcher might operationally define self-esteem as measured by the Personal Worth and Value Questionnaire, as well as a Self-Confidence Inventory, which measures self-esteem con- stitutively defined as “feelings of self-confidence.”
Are the Middle-Range Theory Propositions Reasonable?
The criterion of internal consistency also requires the propositions of the theory to be reasonable. This requirement is called structural consistency (Chinn & Kramer, 2004;
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Fawcett, 1999). Propositions are reasonable when they follow the rules of inductive or deduc- tive reasoning. Reasoning is defined as “the processing and organizing of ideas in order to reach conclusions” (Burns & Grove, 2007, p. 16).
Inductive Reasoning
Inductive reasoning encompasses a set of particular observations and a general conclu- sion. This type of reasoning is “a process of starting with details of experience and moving to a general picture. Inductive reasoning involves the observation of a particular set of instances that belong to and can be identified as part of a larger set” (Liehr & Smith, 2006, p. 114). Inductive reasoning is most often found in reports of theory-generating research. Observations typically are quotations from study participants or are made by the researcher; the conclusion usually is referred to as a category or theme. The general form of inductive reasoning and an example from a fictitious study are given in Box 6–7.
Flaws in Inductive Reasoning
Flaws in inductive reasoning occur when a relevant observation is excluded (Kerlinger & Lee, 2000). For example, suppose that a researcher observed many white swans and con- cluded that all swans are white. The flaw would be discovered when another observation revealed a black swan. Or, suppose that a nurse observed that several people with a medical diagnosis of depression cried a lot and concluded that all people who cry are depressed. The flaw would be discovered when another observation revealed that people who were happy also cried. Consequently, when you evaluate the structural consis- tency of a middle-range theory in a theory-generating research report, consider whether the report includes a sufficient number and variety of observations to support each conclusion.
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BOX 6-7
Inductive Reasoning
General form: Proceeds from the particular to the general Observation: A is an instance of x. Observation: B is an instance of x. Observation: C is an instance of x. Conclusion: A, B, and C make up x.
Example Observation: Doing household chores is a usual activity that is performed less frequently when a person is ill. Observation: Visiting friends is a usual activity that is performed less frequently when a person is ill. Observation: Exercising is a usual activity that is performed less frequently when a person is ill. Conclusion: All usual activities are performed less frequently when a person is ill.
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BOX 6-8
Deductive Reasoning
General form: Proceeds from the general to the particular Premise: If x is related to y, and Premise: if y is related to z, Hypothesis: then x is related to z.
Example Premise: If personal health status is related to self-esteem, and Premise: if self-esteem is related to functional status, Hypothesis: then personal health status is related to functional status.
Example constructed from Newman (2005).
Deductive Reasoning
Deductive reasoning encompasses a set of general propositions and a particular conclusion. This type of reasoning is “a process of starting with the general picture . . . and moving to a specific direction” (Liehr & Smith, 2006, p. 114). The general propositions of deductive rea- soning typically are referred to as premises, axioms, or postulates; the particular conclusion is called a theorem or hypothesis. Premises, axioms, and postulates typically are drawn from literature reviews of previous research and are regarded as empirically adequate statements that do not have to be empirically tested again. A theorem or hypothesis, in contrast, must be test- ed by research. Deductive reasoning is most often found in reports of theory-testing research. The general form of deductive reasoning and an example constructed from Newman’s (2005) study of correlates of functional status of caregivers of children in body casts are given in Box 6–8.
Flaws in Deductive Reasoning
Flaws in deductive reasoning occur when there is an error in a general proposition. Suppose, for example, that a researcher started with the premise that personal health status was related to functional status without providing any supporting research findings, added a premise that functional status was related to self-esteem, and then hypothesized that personal health status was related to self-esteem. The deduction in this example is flawed because the initial premise (personal health status is related to functional status) cannot be regarded as empirically ade- quate prior to testing the statement by conducting research. Although sets of deductive rea- soning statements such as those seen in Box 6–8 are not usually found in research reports, the researcher should provide sufficient support for each hypothesis by citing relevant previous research as part of a critical review of the theoretical and empirical literature. Consequently, when you evaluate the structural consistency of a middle-range theory in a theory-testing research report, consider whether the report includes sufficient information to support any premises and each hypothesis.
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HOW IS THE CRITERION OF PARSIMONY OF THE MIDDLE-RANGE THEORY APPLIED?
Parsimony draws attention to the number of concepts and propositions that make up a middle-range theory. Application of the criterion of parsimony helps you determine whether the middle-range theory is stated as concisely as possible. The same standard of simplicity should be used to evaluate theories that were generated or tested.
The criterion of parsimony is met when you can answer yes to one question:
• Is the middle-range theory stated concisely?
Is the Middle-Range Theory Stated Concisely?
Parsimony requires that a middle-range theory be made up of as few concepts and propositions as necessary to clearly convey the meaning of the theory. Glanz (2002) referred to parsimony as “selective inclusion” of concepts (p. 546). Walker and Avant (2005) explained, “A parsimonious theory is one that is elegant in its simplicity even though it may be broad in its content” (p. 171).
The criterion of parsimony should not be confused with oversimplification of the content needed to convey the meaning of the theory. A theory should not be stated so simply that its meaning is lost. “Parsimony that does not capture the essential features of the [theory] is false economy” (Fawcett, 1999, p. 93). In other words, “A parsimonious theory explains a complex [thing] simply and briefly without sacrificing the theory’s content, structure, or completeness” (Walker & Avant, 2005, p. 172).
A challenge in theory-generating research is to include all relevant data that were collected in one or just a few meaningful categories, rather than a large number of categories, subcategories, and sub-subcategories. For example, a researcher who regards household chores, visiting friends, and exercising as usual activities will present a much more parsimonious theory than a researcher who regards each of those activities as a separate category.
A challenge in theory-testing research is to determine whether the middle-range theory becomes more parsimonious as the result of testing. For example, Tulman and Fawcett (2003) found that several concepts and propositions of their Theory of Adaptation During Childbearing were not supported by their research. They concluded, “The collective quantitative results of our study revealed a somewhat more parsimonious version of the theory” (p. 151). Sometimes, a research report will include diagrams depicting the connections between the middle-range theory concepts before and after testing. Such diagrams can be helpful visual aids to evaluation of parsimony. Figure 6–1 depicts an example from a correlational study of the relations between type of cesarean birth and perception of the birth experience, perception of the birth experience and responses to cesarean birth, and type of childbirth and responses to cesarean birth (Fawcett et al., 2005).
As can be seen in the diagram, the middle-range theory before testing includes links between type of cesarean birth (unplanned and planned) and perception of the birth experi- ence, perception of the birth experience and responses to cesarean birth, and type of cesarean birth and responses to cesarean birth (see Figure 6–1 part A). After testing, the theory includes
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Chapter 6 ■ Evaluation of Middle-Range Theories 83
Perception of the Birth Experience
Responses to Cesarean Birth
Type of Cesarean Birth
A. The Theory Before Testing
Perception of the Birth Experience
Responses to Cesarean Birth
Type of Cesarean Birth
B. A More Parsimonious Theory After Testing
Figure 6-1. Diagrams of middle-range theory propositions before and after testing.
links only between perception of the birth experience and responses to cesarean birth, and type of cesarean birth and responses to cesarean birth (see Figure 6–1 part B). After testing, the the- ory is more parsimonious because no support was found for a link between type of cesarean birth and perception of the birth experience.
HOW IS THE CRITERION OF TESTABILITY OF THE MIDDLE-RANGE THEORY APPLIED?
Testability draws attention to whether the middle-range theory can be empirically tested. Application of the criterion of testability helps you determine whether enough information about the measurement of theory concepts is given in the research report. Enough informa- tion means that you can identify how each concept was operationally defined and how any associations between concepts were determined. The same amount of information about testa- bility should be included in reports of both theory-generating research and theory-testing research.
The criterion of testability is met when you can answer yes to two questions:
• Was each concept measured? • Were all assertions tested through some data analysis technique?
Was Each Concept Measured?
The criterion of testability requires each middle-range theory concept to be empirically observ- able—that is, measurable. The operational definition of the concept identifies the way in which it was measured. A diagram of the C-T-E structure for the research will help you to answer this question. If the research report does not include a C-T-E structure diagram, you can try to
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84 Part 2 ■ Evaluation of Conceptual Models and Theories
BOX 6-9
Applying the Criterion of Testability for Theory- Generating Research
Conceptual Model
Roy’s Adaptation Model
Conceptual Model Concept
Role function mode
Proposition Linking the Conceptual Model Concept to the Empirical Indicator
Development of the Usual Activities Interview Schedule was guided by the role function mode of adaptation.
Operational Definition
Content analysis of data from the Usual Activities Interview Schedule revealed one category, which was labeled “usual activities of ill people.”
Middle-Range Theory Concept
Usual activities of ill people
Descriptive Research Design 30 People Who Had Self-Reported Illness
Usual Activities Interview Schedule Content Analysis
Usual Activities of Ill People
Roy’s Adaptation Model
Role Function Mode
Conceptual Model
Middle-Range Theory
Empirical Research Methods
C-T-E structure for a theory-generating study.
draw one from the written information included in the report. The diagram will enable you to determine whether each concept is connected to an instrument or experimental conditions.
The example in Box 6–9 contains information from a fictitious theory-generating research report. The written information and the C-T-E diagram indicate that the criterion of testability was met. Suppose, however, that another category was mentioned in the report, such as special activities of ill people, and that no information about how the data used to generate the special activities category was given. In that instance, the diagram would not be complete and the cri- terion of testability would not have been met.
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Chapter 6 ■ Evaluation of Middle-Range Theories 85
BOX 6-10
Applying the Criterion of Testability for Theory- Testing Research
Conceptual Model
Roy’s Adaptation Model
Conceptual Model Concepts
• Physiological mode
• Self-concept mode
• Role function mode
Propositions Linking the Conceptual Model and Middle-Range Theory Concepts
• The physiological mode was represented by personal health.
• The self-concept mode was represented by self-esteem.
• The role function mode was represented by functional status.
Middle-Range Theory Concepts
• Personal health
• Self-esteem
• Functional status
Operational Definitions
Personal health was measured by the Personal Health Questionnaire (PHQ). Self-esteem was measured by Rosenberg’s Self-Esteem Scale (RSES). Functional status was measured by the Inventory of Functional Status–Caregiver of a Child in a Body Cast (IFSCCBC).
PHQ
Physiological Mode
Personal Health
Self-Concept Mode
Self-Esteem
RSES
Role Function Mode
Functional Status
IFSCCBC
Roy’s Adaptation Model
Correlational Research Design Correlational Statistics 30 Parents of Children in Body Casts
Conceptual Model
Middle-Range Theory
Empirical Research Methods
C-T-E structure for a theory-testing study.
Example constructed from Newman (2005).
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The example in Box 6–10 contains information found in Newman’s (2005) theory-testing research report. Although Newman did not include a C-T-E structure diagram, it was easily constructed from the written information in the conceptual framework and instruments subsections of the report. The written information and diagram reveal that the criterion of testability was met. Suppose, however, that Newman had not included an operational defini- tion for one of the concepts. In that instance, the diagram would not be complete and the cri- terion of testability would not have been met.
Were All Assertions Tested Through Some Data Analysis Technique?
The criterion of testability requires each assertion made by the middle-range theory propo- sitions to be measurable through some data analysis technique. Although most theory- generating research focuses on the description of a health-related experience in the form of one or a few concepts that are not connected to one another, some theory-generating research reports include propositions that state an association between two concepts. Suppose, for example, that a researcher generated a theory of usual activities of ill people from data col- lected from a group of chronically ill people and a group of acutely ill people. Suppose also that the researcher looked at the list of usual activities for each group, concluded that acute- ly ill people performed different usual activities than chronically ill people, and included a proposition stating that there is an association between the type of illness and the type of usual activities performed. In this example, a proposition stating an association between two concepts—type of illness and usual activities—was generated simply through visual inspec- tion of the data.
Theory-testing research, in contrast, frequently involves use of statistical procedures to sys- tematically test associations between two or more concepts. In theory-testing research, propo- sitions stating associations between concepts, especially when the names of the instruments used to measure the concepts (i.e., the empirical indicators) are substituted for the names of the concepts, are referred to as hypotheses. Each hypothesized association between concepts is tested using a statistical procedure to determine if there is an association between scores from the instruments used to measure the concepts.
The example in Box 6–11 gives the information you should look for in the research report to determine whether the proposition was testable.
Hypothesis Testing
Theory-testing research involves tests of hypotheses. Sometimes, the hypothesis is explicit, and sometimes it is implicit. Explicit hypotheses are, of course, easy to identify because they are labeled as such. For example, a researcher may state that the purpose of the study was to test a particular hypothesis, or a few hypotheses will be listed in the research report. You can iden- tify any implicit hypotheses by systematically examining the research findings and listing all the statistical procedures mentioned in the report. For example, examination of Newman’s
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(2005) research report revealed that she used a correlation coefficient to test the implicit hypothesis of a relation between scores on the Personal Health Questionnaire (PHQ) and scores on the Inventory of Functional Status–Caregiver of a Child in a Body Cast (IFSCCBC).
Hypotheses should be falsifiable (Popper, 1965; Schumacher & Gortner, 1992). That means that the way in which the hypothesis is stated should allow the researcher to conclude that the hypothesis was rejected if the data do not support the assertion made in the hypoth- esis. For example, suppose that a researcher hypothesized that all mothers and fathers have high, medium, or low scores on the IFSCCBC and high, medium, or low scores on the PHQ. The hypothesis cannot be falsified because it does not eliminate any logically or practically possible results. In contrast, the hypothesis that all mothers and fathers have medium scores on the PHQ and low scores on the IFSCCBC can be falsified because it asserts that the moth- ers and fathers will not have high or low scores on the PHQ and will not have high or medium scores on the IFSCCBC.
In addition, it is not correct to conclude that a hypothesis was partially supported. For example, suppose that a researcher hypothesized that both mothers’ and fathers’ scores on the PHQ were related to their scores on the IFSCCBC and that the results indicated that the hypothesis was supported only by the data from the mothers. It would not be correct to con- clude that the hypothesis was partially supported because the mothers’ data supported the hypothesis. Rather, the correct conclusion is that the hypothesis is rejected.
Chapter 6 ■ Evaluation of Middle-Range Theories 87
BOX 6-11
Example of Testability of a Proposition Stating an Association Between Two Concepts
Middle-Range Theory Concepts
• Personal health
• Functional status
Proposition
There is a relation between personal health and functional status.
Operational Definitions
• Personal health was measured by the Personal Health Questionnaire (PHQ).
• Functional status was measured by the Inventory of Functional Status–Caregiver of a Child in a Body Cast (IFSCCBC).
Hypothesis
There is a relation between scores on the PHQ and scores on the IFSCCBC.
Statistical Procedure
A Pearson coefficient of correlation was used to determine the correlation between scores from the PHQ and the IFSCCBC.
Example constructed from Newman (2005).
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Conclusion
In this chapter, you continued to learn about how to determine how good the information about a middle-range theory given in a research report is. Specifically, you learned how to evaluate the T component of C-T-E structures using the criteria of significance, internal consistency, parsi- mony, and testability. The questions to ask and answer as you evaluate the middle-range theory are listed in Box 6–12. Application of these four criteria should help you to better understand the link between the T and E components of C-T-E structures. The learning activities for this chapter will help you increase your understanding of the four criteria and their application to the contents of research reports.
References
Full citations for all references cited in this chapter are provided in the Reference section at the end of the book.
Learning Activities
Activities to supplement what you have learned in this chapter, along with practice examina- tion questions, are provided on the CD that comes with this book.
88 Part 2 ■ Evaluation of Conceptual Models and Theories
BOX 6-12
Evaluation of Middle-Range Theories: How Good Is the Information?
Significance
• Is the middle-range theory socially significant?
• Is the middle-range theory theoretically significant?
Internal Consistency
• Is each concept of the middle-range theory explicitly identified and clearly defined?
• Are the same term and same definition used consistently for each concept?
• Are the propositions of the middle-range theory reasonable?
Parsimony
• Is the middle-range theory stated concisely?
Testability
• Was each concept measured?
• Were all assertions tested through some data analysis technique?
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1
Middle Range Theory Evaluation
Name
Walden University
Theoretical and Scientific Foundations for Nursing Practice
NURS 8110
Date
2
Middle Range Theory Evaluation
Ingenious words articulated by the Hmong people are as follows: “when crossing a river,
remove your sandals; when crossing a border, remove your crown (Lor, Xiong, Park, Schwei, &
Jacobs, 2017, p. 408).” This proverb is inspiratory pertinent to the objectives of this author in
pursuit of nursing excellence. What wisdom may be translated from this Hmong aphorism and
found useful to the nursing discipline? The elucidation here of Hmong insight is as if they
desired to paint a picture for the conscious efforts vital to the achievement of cultural humility.
How does this relate to middle range theory?
Cultural congruency, requisite of humility, is imperative to optimal outcomes in the
nurse-patient relationship (Elminowski, 2015). The practice of humility by the nurse in settings
of diversity of culture promotes understanding and circumvention of cultural impositioning
(Isaacson, 2014). The misperception of capacity to practice cultural competency facilitates
hierarchical care, power imbalances, social injustices, and health disparities (Foronda, Baptiste,
Reindholdt, & Ousman, 2015). In the vast multicultural modern realm, continuing a remiss quest
for cultural competency gravely hinders patient care outcomes, whereas, upholding a vision of a
preferred future of universality of care exempt from bias is the pathway to nursing excellence.
Critical to this conquest is the augmentation of pertinent nursing knowledge; the evaluation of
theory is elementary to the propositioned developments. The purpose of this paper is to evaluate
the Culture Care: Diversity and Universality Theory and the Interpersonal Relations in Nursing
Theory from the context of a petition for cultural humility as the alternative to the solecism of
cultural competency.
3
Theory of Culture Care: Diversity and Universality
Summary
Madeleine Leininger contributed to the progression of nursing with her innovative
conceptual framework and theoretical development of cultural awareness. Leininger’s research
resulted in the birth of transcultural nursing with a focus on improvements in nurse-client
relationship outcomes when culturally congruent holistic care is present (Sitzman &
Eichelberger, 2015). Her explicit theory is one of middle range upper level with the basic tenets
offered as care being the essence of nursing as well as a direct action and cultural care and
sensitivity as the understanding and incorporation of values and beliefs of the patient to
positively influence health or illness. Further tenets presented are diversity as respect for
practices within cultures and universality as acceptable practices across cultures (McEwen &
Wills, 2014). Leininger accentuated the cultural awareness of the nurse combined with co-
participation in decision making with the client as necessary for delivery of meaningful and well-
received care (Sitzman & Eichelberger, 2015). Although implicit, she thoroughly presented the
detrimental impact of cultural impositioning to nursing.
Evaluation
Social significance.
The importance of a theory to society is appraised by its ability to meet the criterion of
significance (Fawcett & Garity, 2009). The use of this model for research in cultural humility is
socially significant. The general public is culturally diverse. Nursing care receptive of cultural
differentiations without assumptions improves health outcomes of the vulnerable (Horvat, Horey,
Romios, & Kis-Rigo, 2014).
4
Theoretical Significance
The criterion of significance is further examined in the theory’s facilitation of novel
awareness pertinent to the proposed contextual application of the investigated problem (Fawcett
& Garity, 2009). Previous studies of the concept of cultural competency have revealed increased
unresponsiveness to the culturally diverse patient leading to potential adverse patient safety
issues (Isaacson, 2014). Bringing awareness to the mindful utilization of humility rather than the
unconscious act of superiority in the nurse-client relationship is theoretically significant.
Internal Consistency
Semantic clarity is present when there are theoretical and operational definitions of all
concepts (Fawcett & Garity, 2009). Leininger’s model is inclusive of both constitutive and
operational definitions of each of her concepts. Clarity is sustained in this theory with no
deviation in the above definitions thereby meeting semantic consistency. The propositions of this
theory are reasonable together with inductive and deductive observations thus giving structural
consistency.
Parsimony
Is there elegance in simplifying the complexity of the theory while maintaining meaning
(Fawcett & Garity, 2009)? The Theory of Culture Care: Diversity and Universality is succinct
and supported by Leininger’s Sunrise Model (McEwen & Wills, 2014).
Testability
Leininger’s theory is able to be empirically tested. The model has been confirmed using
techniques in quantitative and qualitative research and is capable of meeting criterion with use of
the C-T-E structural diagram (Elminowski, 2015; Fawcett & Garity, 2009; Long, 2016; Yeager
& Bauer-Wu, 2013). The model continues to be tested with use of countless culturalogical
5
assessment tools (Ethnomed website, n.d.; University of Washington Medical Center website,
n.d.; U.S. Department of Health and Human Services, Health Resources and Services
Administration, n.d.). Additionally, be it noted hypotheses testing is profitable in determining the
truism of observable outcomes (Fawcett & Garity, 2009; Im, 2015). Leininger’s model is explicit
in hypothesizing positive change in outcomes in healthcare as having more than a chance
relationship with the variables of employed transcultural nursing concepts and research findings.
Theory of Interpersonal Relations in Nursing
Summary
The aftereffect of order change within the discipline of nursing cultivated by Hildegard
Peplau in 1952 has had substantial impact on the nurse-client relationship (D’Antonio, Beeber,
Sills, & Naegle, 2013). Prior to Peplau, nursing was focused on what nurses did to their patients;
Peplau transformed this emphasis to what nurses did with their patients (Sitzman & Eichelberger,
2015). Peplau propositioned the core of nursing to emanate from achievement of mutualistic
relationships cognizant of individual traits of clients and self-awareness of nurses. Thus, implicit
in her model may have been the most primitive attempt to embrace cultural diversity and
encourage humility through construct of collaborative relationships in trade for authoritative.
Peplau’s theory is middle range descriptive with influences from Henry Stack Sullivan and
Abraham Maslow (McEwen & Wills, 2014).
Evaluation
Social Significance
Use of Hildegard Peplau’s theory for research in cultural humility is socially significant.
The multiculturalism of the general public continues to breed concomitant with advancements in
global mobility. Reduction in health disparities amongst the vulnerable necessitates supportive
6
interpersonal relations inclusive of humble attitude, openness, and equitable belief in human
rights (Foronda et al., 2015).
Theoretical Significance
Peplau’s innovative insight into concentration on patient experiences and stories as
fundamental to nursing care provides theoretical significance (Hagerty, Samuels, Norcini-Pala,
& Gigliotti, 2017). Her philological of listening to the patient with reverence for dignity was
pioneering over 50 years ago and remains seminal today in theoretical developments and
researchability in nursing as well as other fields. Cultural sensitivity is offered as necessary to the
interpersonal relationship (Karnick, 2013).
Internal Consistency
Semantic clarity is present in this theory in a manner fairly divergent in that Peplau
identifies the major concepts and offers constitutive definitions; subconcepts are propositioned
with operational definitions (Sitzman & Eichelberger, 2015). Semantic consistency is peculiar in
this theory, yet, maintained as operational definitions are plural while upholding constitutive
measures (Fawcett & Garity, 2009). The propositions are reasonable in simplicity giving
generalizability with inductive reasoning, however, limited in precision and hypothetical testing
as deductive reasoning (Im, 2015).
Parsimony
Peplau’s theory is parsimonious. She offers a modest number of concepts and
propositions thereby capturing her essential features without loss of content (Fawcett & Garity,
2009). Her diagrams are supportive of said parsimony and the links within the nurse-patient
relationship (Hagerty et al., 2017).
7
Testability
There has not been an abundant amount of formal testing of Peplau’s theory (Karnick,
2013). Nonetheless, it is considered to have capacity for empirical testing (Hagerty et al., 2017).
The structure of the model has been utilized in quantitative and qualitative research testing in
less than excessive amounts with good fit outcomes (Hagerty et al., 2017). Peplau’s interpersonal
theory has performed well in testing of pedagogical application in practice (Reid Searl et al.,
2014). Explicit hypothetical testing is limited due to inability to rule out chance difference versus
relational difference in patients who are not able to return communication.
Theoretical Selection
It is conceivable that either of the theories evaluated above may be suitable for the
investigation of cultural humility and its influence on nursing and healthcare. Both theories are
observed in their evaluations to be well-executed, have significance to the nurse and the patient,
and exhibit call for our discipline to transform from merely disease orientation to psychodynamic
nursing interventions (Foronda et al., 2015; Hagerty et al., 2017; Isaacson, 2014). Both theorists
incorporate the concept of individual culture of the patient as components in their philosophies.
Hildegard Peplau’s limelight on collaborating as one with the patient, devising care apropos to
the individuality of the patient, and nurse self-awareness does implicitly address culture. The
propositions of Madeline Leininger’s theory, inclusive of Peplau’s trinity above, are more easily
defined or explicit of cultural integration and its prominence on nurse-patient outcomes.
Leininger’s theory is not more correct than Peplau’s nor is the contrary accurate. Both
ladies’ theoretical contributions have revolutionized the practice of nursing with expansion of
concepts not considered prior, enhancement of research, and reflection-stimulated modifications
in patient care (Sitzman & Eichelberger, 2015). As a lifelong learner, it is this author’s
8
responsibility to systematically evaluate which theory offers the most usefulness in fortifying
personal professional practice (Sitzman & Eichelberger, 2015).
The Theory of Culture Care: Diversity and Universality is deemed most appropriate for
exploration of the clinical practice problem of awareness, comprehension, and application of
cultural humility as opposed to the unbefitting and antiquated schooling of cultural competency.
As above, Leininger’s propositions are precise, thus, allowing for objectification of criteria and
hypotheses testing of the conceptual framework of cultural humility. The theory-testing research
encompassing of these propositions are anticipated to generate said hypotheses that are found
falsifiable in regards to the assertion of the duty of the nurse to provide cultural humility,
thereby, giving truism to the vision of the author (Fawcett & Garity, 2009). Peplau’s
propositions, although profound, have confines relative to testability apposite of culture leading
to reduction in generalizability. As a doctoral candidate, this author is attentive to the impending
capstone resulting in local practice generalizability that is correspondingly worthy of
contribution to the nursing profession (Walden University, 2015).
Refinement of Clinical Practice Question
At commencement of assignment, the intent of this author was to delineate the betterment
of cultural congruence with adoption of cultural humility as alternative to cultural competence.
The labors invested here in the scholarly evaluations of theory produced an opinion that is more
informed regarding progression of the approaching doctoral study. As such, the amended and
now well-formulated PICOT is as below. Noted is the adjustment is surmised compulsory
pertinent to deductive reasoning and generalizability (Fawcett & Garity, 2009; Im, 2015;
Karnick, 2013; McEwen & Wills, 2014; Sitzman & Eichelberger, 2015). Further noted is the
clinical inquiry to be formatted as an intervention PICOT (Melnyk & Fineout-Overholt, 2014).
9
Patient population: Patients of culturally diverse backgrounds incongruent with nurse
Intervention: Staff education program to improve cultural awareness and cultural
sensitivity.
Comparison: No education (no comparison group as all staff will be offered education).
Outcome: Evaluation of knowledge pre-and post-education.
Clinical practice question: In patients of culturally diverse backgrounds incongruent with
the nurse (P), how does an education program aimed at improving staff education by the nurse
(I) improve staff knowledge regarding cultural sensitivity? (O)
Summary
It is the long-term ambition of this author to alter the delivery of nursing care to that
which is congruent with the process of cultural humility; courage to remove one’s crown
becomes an expectation of the healthcare professional. Perceptions of hierarchy and pretense no
longer exist in a preferred future of nursing excellence. Values, beliefs, and practices of all
patients are explored and embraced with tender of egoless tactics. Advanced practice nurses are
stellar advocates of cultural humility recognizing its exercise as not only duty but privilege.
Paternalistic behaviors are shunned practices of the past. In their shoes, respect, equality, social
justice, and elimination of health disparities walk freely.
10
References
D’Antonio, P., Beeber, L., Sills, G., & Naegle, M. (2013). The future in the past: Hildegard
Peplau and interpersonal relations in nursing. Nursing Inquiry, 21(4), 311-317. doi:
10.1111/nin.12056
Elminowski, N. S. (2015). Developing and implementing a cultural awareness workshop for
practitioners. Journal of Cultural Diversity, 22(3), 105-113. Retrieved from
http://web.a.ebscohosst.com.ezp.waldenlibrary.org
Fawcett, J., & Garity, J. (2009). Evaluation of middle-range theories. In Evaluating research for
evidence-based nursing (Ch. 6). Retrieved from academicguides.waldenu.edu
Foronda, C., Baptiste, D., Reindholdt, M. M., & Ousman, K. (2015). Cultural humility: a concept
analysis. Journal of Transcultural Nursing, 27(3), 210-217. doi:
http://dx.doi.org.ezp.waldenulibrary.org/10.1177/104365961552677
Hagerty, T. A., Samuels, W., Norcini-Pala, A., & Gigliotti, E. (2017). Peplau’s theory of
interpersonal relatons: an alternate factor structure for patient experience data. Nursing
Science Quarterly, 30(2), 160-167. doi: 10.1177/089-4318417693286
Horvat, L., Horey, D., Romios, P., & Kis-Rigo, J. (Eds.). (2014). Cultural competence education
for health professionals. Cochrane Database of Systematic Reviews, 1-100. Retrieved
from http://web.b.ebscohost.com.ezp.waldenulibrary.org
Im, E. (2015). The current status of theory evaluation in nursing. Journal of Advanced Nursing,
71(10), 2268-2278. doi: http://dx.doi.org.ezp.waldenulibrary.org/10.1111/jan.12698
Isaacson, M. (2014). Clarifying concepts: cultural humility or competency. Journal of
Professional Nursing, 30(3), 251-258. doi:
http://dx.doi.org/10.1016/j.profnurs.2013.09.011
11
Karnick, P. M. (2013). The importance of defining theory in nursing: is there a common
denominator? Nursing Science Quarterly, 26(1), 29-30. doi: 10.1177/0894318412466747
Long, T. (2016). Influence of international service learning on nursing students’ self-efficacy
towards cultural competence. Journal of Cultural Diversity, 23(1), 28-33. Retrieved from
http//eds.b.ebscohost.com.ezp.waldenlibrary.org
Lor, M., Xiong, P., Park, L., Schwei, R. J., & Jacobs, E. A. (2017). Western or traditional
healers? Understanding decision making in the Hmong population. Western Journal of
Nursing Research, 39(3), 400-415. doi:
http://dx.doi.org.ezp.waldenulibrary.org/10.1177/0193945916636484
McEwen, M., & Wills, E. M. (2014). Theoretical basis for nursing (4th ed.). Philadelphia, PA:
Wolters Kluwer/Lippincott Williams & Wilkins.
Melnyk, B. M., & Fineout-Overholt, E. (2014). Evidence-based practice in nursing &
healthcare: a guide to best practice (3rd ed.). Philadelphia, PA: Wolters
Kluwer/Lippincott Williams & Wilkins.
Reid Searl, K., McAllister, M., Dwyer, T., Krebs, K., Anderson, C., Quinney, L., & McLellan, S.
(2014). Little people, big lessons: an innovative strategy to develop interpersonal skills in
undergraduate students. Nurse Education Today, 34(9), 1201-1206. Retrieved from
http://web.a.ebscohost.com.ezp.waldenulibrary.org
Sitzman, K. L., & Eichelberger, L. W. (2015). Understanding the work of nurse theorists: a
creative beginning (3rd ed.). Sudbury, MA: Jones & Bartlett Learning.
Walden University. (2015, September). Doctoral project premise: doctor of nursing practice
(Educational Standard). Retrieved from Walden University website:
12
Yeager, K. A., & Bauer-Wu, S. (2013). Cultural humility: essential foundation for clinical
researchers. Applied Nursing Research, 26, 251-256. doi:
http://dx.doi.org/10.1016/j.apnr.2013.06.008
13
NURS 8110 Grading Rubric Week 10 Application 5: Middle Range or Interdisciplinary Theory Evaluation [MA3]
Points Possible
Points Earned
Briefly describe your selected clinical practice problem. 3
Summarize the two selected theories. Both may be middle range theories or interdisciplinary theories, or you may select one from each category.
6
Evaluate both theories using the evaluation criteria provided in the Learning Resources.
6
Determine which theory is most appropriate for addressing your clinical practice problem. Summarize why you selected the theory. Using the propositions of that theory, refine your clinical / practice research question.
6
Cover Page/Overall APA/Reference Page 5 Total Points 26 Comments:
MEDSURG Nursing—November/December 2010—Vol. 19/No. 6 317
Michael M. Evans, MSN, RN, CNS, CMSRN, is an Instructor of Nursing, The Pennsylvania State University Worthington Scranton Campus, Dunmore, PA.
Acknowledgment: I would like to thank Karen Paczkowski, MD, with Physicians Health Alliance, for her help and guid- ance in implementing this project, as well as Dr. Cindy Mailloux and Dr. Jean Steelman, nursing faculty with Misericordia University, for their sup- port and guidance in implementing the project.
Michael M. Evans
Evidence-Based Practice Protocol to Improve Glucose Control in
Individuals with Type 2 Diabetes Mellitus
Diabetes mellitus (DM) is a group of diseases that includes type 1 DM,type 2 DM, gestational DM, medication-induced DM, and pre-DM; all are characterized by high levels of blood glucose (American Diabetes Association [ADA], 2008). Currently, 24 million children and adults in the United States (8% of the population) have diabetes; unfortunately, nearly one-third of those individuals are unaware they have the disease. In addi- tion, 57 million Americans have pre-diabetes (ADA, 2007a). Type 2 DM accounts for 90%-95% of all cases of diabetes (Centers for Disease Control, 2003). In type 2 DM, the body does not use insulin properly due either to insulin resistance or relative insulin deficiency (ADA, 2007a).
In 2000, DM was the sixth leading cause of death in the United States, with heart disease leading the cause of diabetes-related deaths. About 65% of deaths occurring among people with DM are attributed to heart disease or stroke. DM is the leading cause of blindness among adults ages 20-74, and diabetic retinopathy is linked to 12,000-24,000 new cases of blindness each year. In 2000, nearly 130,000 people with DM underwent dialysis treatment or kidney transplantation. About 60%-70% of people with DM also have mild-to-severe forms of nervous system damage that impairs sensation in the feet or hands and slows digestion of food in the stomach. Also, more than 60% of non-traumatic lower-limb amputations in the United States occur among people with DM (ADA, 2007a).
To determine if a person has pre-diabetes or diabetes, health care providers conduct a fasting plasma glucose test (FPG) or an oral glucose tolerance test. Either test can be used to diagnose pre-diabetes or dia- betes; however, the ADA (2007b) recommends the FPG because it is easi- er, faster, and less expensive to perform. A fasting blood glucose level of 100-125 mg/dl signals pre-diabetes, while FPG greater than 125 mg/dl sig- nifies diabetes (ADA, 2007b). DM contributes to many complications which are very costly to patients and the U.S. health care system. Direct medical costs related to DM in 2007 were $116 billion, while indirect costs (e.g., disability, work loss, premature mortality) accounted for $58 billion. Total costs related to DM in the United States in 2007 were $174 billion (ADA, 2008). In Pennsylvania, where the APRN intervention occurred, direct medical costs related to DM in 2006 were estimated at nearly $5 bil- lion and indirect costs at a little over $2 billion (ADA, 2006).
Research has shown that keeping blood glucose results as close to normal as possible can prevent or delay many of the complications and costs associated with DM. The classic randomized clinical trial conducted by The Diabetes Control and Complications Trial Research Group (1993) found maintenance of blood glucose as close to normal as possible slows the onset and progression of diabetes-related eye, kidney, and nerve dis-
Type 2 diabetes mellitus is a major public health prob- lem in the United States. In adult patients with type 2 DM, what is the effect of adding a follow-up telephone intervention by an APRN on blood glucose control as com- pared to standard treatment alone? Findings from one sys- tematic review and five ran- domized control trials were used to support a protocol to elicit improvement in gly – cemic control.
Evidence-Based Practice
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eases. The findings showed a reduction in eye disease by 76%, kidney disease by 50%, and nerve disease by 60%. The study also demonstrated any sustained low- ering of blood glucose has positive effects, even if the person has a history of poor glycemic control. The United Kingdom Prospective Diabetes Study (1998) also con- cluded intensive blood glucose control decreases the risk of microvascular complications and diabetes-related deaths.
To maintain tight glycemic control, the literature strongly sup- ports use of the ADA Standards of Medical Care in Diabetes (2007b). Standards currently do not recom- mend a follow-up telephone inter- vention, but they do encourage use of a complex treatment regime for persons with type 2 diabetes in order to maintain tight glycemic control and delay or minimize diabetes-related complications. Because many persons diagnosed with type 2 diabetes are older adults, complex treatments may be difficult to implement. Involve – ment of an advanced practice nurse (APN) may empower patients to care for their chronic illness and maintain their optimal level of wellness. The purpose of this article is to explore the effec- tiveness of an APN-led follow-up telephone intervention on gly – cemic control in individuals with type 2 DM. The effectiveness of the intervention was measured by the interpretation of daily fasting blood glucose results.
Focused Problem In adults with type 2 DM, what
is the effect of adding a follow-up telephone intervention by an APN on blood glucose control as com- pared to ADA-recommended stan- dard treatment alone? Target pop- ulation for the intervention was adults diagnosed with type 2 DM who could read, write, and under- stand English; were able to per- form self-blood glucose monitoring every day before eating; and were willing to call or fax the results to the collaborating physician’s office on a weekly basis. Excluded from the evidence-based practice proto- col (EBPP) were persons with a diagnosed psychotic disorder or
disabling sensory or cognitive impairment; who had a new diag- nosis of type 2 DM and had not attended standard outpatient DM education classes; were receiving drugs that can cause medication- induced hyperglycemia or hypo- glycemia (steroids, antibiotics) at the time of APN intervention implementation; and patients with an acute illness that may cause hyperglycemia. Individuals who were pregnant or planning to become pregnant, those without access to a telephone, those with- out a blood glucose monitor or without access to one, persons with hypoglycemia unawareness, and those with a life expectancy of less than 1 year were excluded from the EBPP.
Intended users of the EBPP included adult health clinical nurse specialists, family and adult nurse practitioners, and internal medicine and family physicians with whom an APN could collabo- rate to initiate the stated interven- tion. Other potential beneficiaries of the EBPP were all health care professionals who have direct con- tact with individuals with type 2 DM and can facilitate their appro- priate referrals and education.
The objective of the EBPP pro- tocol was to improve glucose con- trol in individuals with type 2 DM, as demonstrated through the trending of FBG results. The ADA (2007b) recommends self-monitor- ing of blood glucose (SMBG) as a component of effective therapy that allows patients to evaluate their individual responses to thera- py and assess whether glycemic targets are being reached. SMBG can be useful in preventing hypo- glycemia, adjusting medications, and identifying effects of physical activity. The optimal frequency and timing of SMBG for patients with type 2 DM is not known but should be sufficient to facilitate attainment of glucose goals. Use of hemoglobin A1c testing in combina- tion with SMBG allows better eval- uation of blood glucose manage- ment as well as verification of accuracy of self-reported blood glucose results. However, inclu- sion of this measure was not possi- ble in the current study.
Literature Review A literature review was per-
formed for the most current and rel- evant information related to the research question. Six computer- ized research data bases were accessed: Cumulative Index to Nursing and Allied Health Literature (CINAHL), Health Source: Nursing/Academic Edition, MED- LINE, Educational Resource Information Center (ERIC), the Cochrane Library, and DiabetesPro (professional resources online). The keywords used to retrieve doc- uments were diabetes mellitus, type 2 diabetes mellitus, diabetes melli- tus and follow-up interventions, dia- betes mellitus and follow-up inter- ventions and advanced practice nursing, diabetes mellitus and fol- low-up interventions and clinical nurse specialists, diabetes mellitus and follow-up interventions and meta analysis, diabetes mellitus and follow-up interventions and system- atic reviews, diabetes mellitus and follow-up phone call interventions, diabetes mellitus and nursing educa- tion, diabetes mellitus and glucose control, diabetes mellitus and glu- cose control and advanced practice nursing, diabetes mellitus and glu- cose control and clinical nurse spe- cialists. After completion of the lit- erature review, 22 studies were reviewed for the EBPP; however, only six studies (1999-2007) met the selection criteria based for the proposed APN intervention. One study was a systematic review, and five studies were randomized con- trol trials.
The selected studies suggest- ed follow-up phone call interven- tions can help improve glycemic control in individuals with DM.
Conceptual Model The conceptual model used to
direct the EBPP was Dorthea Orem’s Self-Care Deficit Theory of Nursing. Within Orem’s conceptual model, three theories are expressed: theory of nursing sys- tems, theory of self-care deficit, and theory of self-care. The cur- rent study was based on Orem’s Mid-Range Theory of Self-Care, which identified self-care as “a human regulatory function that individuals must, with delibera- tion, perform themselves or have
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performed for them to maintain life, health, development, and well being” (Orem, 1995, p. 103). The theory of self-care was related to the EBPP because individuals with type 2 DM must adhere to treat- ment guidelines (self-care) in order to maintain life, health, develop- ment, and well-being, as evidenced by improved glycemic control and blood sugar stability. The APN intervention served as one method to facilitate self-care.
Major Recommendations Two guidelines were reviewed
using the Appraisal of Guidelines for Research and Evaluation (AGREE) Instrument (2001) to for- mulate the APN algorithm (see Figure 1) and questions (see Figure 2) in the follow-up phone call inter- vention. The Standards of Medical Care in Diabetes (ADA, 2007b) guided the formulation of ques- tions and recommendations in – volving diabetes management. The intervention included questions and recommendations about appropriate medical evaluations, management plans, SMBG, diag- nostic testing, physical activity,
psychosocial assessment, immu- nizations, hypoglycemia/hyper- glycemia problems, sick day guide- lines, hypertension control, lipid management, aspirin therapy, smoking cessation, foot care, and nephropathy/retinopathy screen- ing, and treatment.
Based on the guidelines (ADA, 2007b), patient recommendations were made during the APN inter- vention, including SMBG for achievement of glycemic goals and hemoglobin A1c testing at appropri- ate intervals. Meal planning (car- bohydrate counting and limiting
Figure 1. Type 2 DM Follow-Up Phone Call Treatment Algorithm:
A Coaching/Collaboration Protocol
Adult with type 2 DM who has attended standard
ADA outpatient DM education classes.
Schedule initial visit with APN to discuss DM
treatment plan.
During bi-weekly follow-up phone calls, discuss ADA
standards of care and record FBG results.
Effectiveness of EBPP measured through an
improvement in FBG results
Unwilling to participate in EBPP
Comparison Group: No further reminders regarding plan of care
Provide recommendations following ADA standards of care
based on patient responses.
Collaborate with physician as necessary to adapt plan of care.
Intervention Group: Begin proposed
treatment modality with follow-up phone call
intervention.
Willing to participate in EBPP
Obtain PMH to ensure criteria are met for EBPP.
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fat intake) and physical activity of at least 150 minutes/week were discussed with all patients, and a brief psychosocial assessment was performed on all patients in the EBPP as a screening for any emo- tional problems. Also discussed was treatment of hypoglycemia with 15-20 grams of a rapid-acting carbohydrate. The importance of obtaining the pneumococcal vac- cine and the annual influenza vac- cine also was identified.
Other patient recommenda- tions included blood pressure screening to identify individuals with hypertension and further treatment involving medications, lifestyle, and behavioral therapy. Dyslipidemia screening was rec- ommended annually, or more fre- quently based on lipid values, in order to achieve goals and treat- ment with a HMG-CoA reductase
inhibitor medication (statin) for all patients trying to achieve a reduc- tion in low-density lipoprotein (LDL) of 30%-40% regardless of baseline LDL levels. Also, aspirin therapy was recommended as a primary prevention strategy for individuals with an increased risk of cardiovascular disease and as a secondary prevention strategy in persons with a history of cardio- vascular disease. All patients in the EBPP were advised not to smoke.
Patients also were advised to perform an annual test for the presence of microalbuminuria and receive appropriate pharma- cotherapy if indicated. Yearly dila- tion and comprehensive eye exam- inations by an ophthalmologist or optometrist were recommended to reduce the risk and progression of diabetic retinopathy. Finally, a
comprehensive foot exam was rec- ommended annually to patients in the EBPP to identify risk factors predictive of ulcers or amputa- tions, or identify any areas of skin breakdown.
Risks and Benefits of the Guideline
Risks of following the guide- lines included events such as severe hypoglycemia and weight gain, which is attributed to the improved glycemic control. Other risks involved liver dysfunction from statin therapy and fluid reten- tion for patients receiving oral thi- azolidinediones for hyperglyce – mia. Benefits of following the guidelines included the opportuni- ty for optimal management of dia- betes involving improved glycemic control as well as appropriate pre- vention and management of dia- betes complications (ADA, 2007b).
Implementation of the Guideline
Implementation of the EBPP occurred with oversight of a col- laborating preceptor, Dr. Karen Paczkowski, a practitioner with Physician Health Alliance. The process evolved over an 8-week period and began with an initial face-to-face meeting in which the patient was asked to join the EBPP and participate in follow-up tele- phone calls at mutually deter- mined times. The proposed algo- rithm allowed patient coaching for improved blood glucose control. In addition, collaboration with a physician permitted necessary medication adjustments and changes, diagnostic tests, and additional referrals when neces- sary to assist the patient to improve blood glucose control and self-care by eliminating the knowl- edge deficit. Initial face-to-face office visits with the APN followed by bi-weekly telephone contact also helped to guide patients in assumption of self-care and improved adherence to the treat- ment regime. The intervention environment supported personal development by allowing patients to discuss areas of concern or interest and by APN coaching.
Fasting blood glucose (FBG) results were used as the outcome
The following will be covered in the 15-20 minute bi-weekly phone call: 1. Do you have a follow-up appointment with your primary care provider? 2. Are you self-monitoring your blood glucose levels at home? 3. If yes, how often? 4. Are you satisfied with your blood glucose monitor? 5. What were your blood glucose values over the last 48 hours? 6. Are you going to have a HgbA1c drawn within next 3-4 months? 7. If previously done, what was the value? 8. Are you taking medication for your DM? 9. If yes, what medications? 10. If yes, are you having any problems with it? 11. Any hyperglycemia or hypoglycemia problems? 12. What was your blood pressure at your last screening? 13. If it was greater than130/80, are you being treated with lifestyle and behavioral
changes (exercise, diet modifications)? 14. If it was greater than 140/90, are you being treated with medication as well as
lifestyle and behavioral changes? (preferably ACE inhibitors or ARBs as they have been shown to delay the progression of macroalbuminuria and nephropathy)
15. What was your last cholesterol level? 16. Are you taking a statin (shown to delay onset of CVD)? 17. Do you take an aspirin daily (75-162 mg/day)? 18. Have you been tested for the presence of microalbuminuria? 19. If present, are you currently taking an ACE inhibitor or an ARB? 20. Have you had a dilated and comprehensive eye examination by an
ophthalmologist or optometrist since diagnosis? 21. Have you had a foot examination since diagnosis? 22. Provide smoking cessation counseling. 23. Have you had the flu shot this year? 24. Is your pneumonia vaccine up to date? 25. Discuss sick day guidelines. 26. Are you getting exercise of moderate intensity at least three times a week for
30 minutes at a time? 27. Discuss meal planning. 28. How are you feeling emotionally? 29. Is there anything that we have not discussed that you would like to discuss
concerning your treatment plan?
Figure 2. Content of Follow-Up Telephone Intervention
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measure and recorded with each telephone intervention so trends could be tracked and medication changes or adjustments, diagnos- tic testing, and appropriate refer- rals made by the collaborating physician when necessary. As shown in Figure 3, a downward trend of FBG occurred in the inter- vention group. Also, participants in the intervention group received advanced coaching on the latest ADA standards of care by an APN. The comparison group received the ADA standards of care and called or faxed in their FBG results bi-weekly to the collaborating physician’s office but received no APN intervention.
Discussion As displayed in Figure 3, the
EBPP showed a significant reduc- tion in FBG results of 72 mg/dL, correlating to 2% decrease in hemoglobin A1c (ADA, 2007b). However, bias might have influ- enced the results in a nonhomoge- neous sample because of conven- ience sampling and time con- straints. The sample of the inter- vention group was all female, ages 69-79, whereas the comparison group had male and female partici- pants ages 39-87. Baseline hemo- globin A1c was 5.9%-9.5% for the intervention group and 6.9%-8.2% for the comparison group. Also, participant contamination may have occurred during the APN intervention. As shown in Figure 4, participants in the comparison group benefitted from the collabo- rative efforts of the APN and physi- cian regarding elevated FBG results. They did not receive the bi-weekly follow-up telephone intervention but may have received a medication adjustment or change in treatment regime in order to improve glycemic control. However, the intervention group maintained better glycemic con- trol as compared to the compari- son group (see Figure 5).
Limitations Limitations of the EBPP includ-
ed time constraints, which did not allow for hemoglobin A1c testing, self-reported FBG data, failure to limit extraneous variables (includ-
Figure 5. Differences Between Intervention and Comparison Groups
Figure 3. Comparison of Intervention Group Before and
After APN Intervention
300 250 200 150 100 50 0
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Figure 4. Differences of Comparison Group Before and
After APN Intervention
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200
150
100
50
0
B lo
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ing glucometer malfunction), and a small sample size (six participants in each groups). In addition, one individual in the intervention group required surgery and anoth- er required corticosteroid treat- ment during the EBPP, interven- tions that may have altered FBS results.
Even with these limitations, the author still finds the results clinically significant. The APN intervention may have been more successful than interventions in reviewed literature (Aubert et al., 1998; Maljanian, Grey, Staff, & Conroy, 2005; Oh, Kim, Yoon, & Choi, 2003; Piette et al., 2000; Wong, Mok, Chan, & Tsang, 2005) due to the educational knowledge and training of APNs.
Conclusion According to Bourbonniere
and Evans (2002), “An APRN demonstrates a high level of expertise in assessing, diagnosing, and treating complex health responses of individuals, groups, and communities. Through the lens of their expert skills, interventions are based on greater depth and breadth of knowledge and a finely honed ability to synthesize physio- logical, psychological, social, and environmental data” (p. 2062). The EBPP’s impact may have been due in part to the APN’s holistic view of the patient, who received care con- sistent with ADA (2007b) recom-
mendations with the addition of the APRN intervention.
References American Diabetes Association (ADA).
(2006). The estimated prevalence and cost of diabetes in Pennsylvania. Retrieved from http://www.diabetes arch ive.net /advocacy-and- lega l resources/cost-of-diabetes-results. jsp?state=Pennsylvania&distr ict= 0&DistName=Pennsylvania+%28Entire +State%29
American Diabetes Association (ADA). (2007a). Diabetes statistics. Retrieved from http://www.diabetes.org/diabetes- basics/diabetes-statistics/
American Diabetes Association (ADA). (2007b). Standards of medical care in diabetes-2007. Retrieved from http:// care.diabetesjournals.org/content/30/ suppl_1/S4.full
American Diabetes Association (ADA). (2008). Economic costs of diabetes in the U.S in 2007. Retrieved from http:// care.diabetesjournals.org/content/ 31/3/596.full.pdf+html
Aubert, R.E., Herman, W.H., Waters, J., Morre, W., Sutton, D., Peterson, B.L., … Koplan, J.P. (1998). Nurse case man- agement to improve glycemic control in diabetic patients in a health mainte- nance organization. Annals of Internal Medicine, 129(8), 605-612.
Bourbonniere, M., & Evans, L. (2002). Advanced practice nursing in the care of frail older adults. Journal of American Geriatric Society, 50(12), 2062-2076.
Centers for Disease Control. (2003). 2003 National diabetes fact sheet. Retrieved from http://www.cdc.gov/diabetes/pubs/ general.htm#what
Maljanian, R., Grey, N., Staff, I., & Conroy, L. (2005). Intensive telephone follow-up to a hospital-based disease management model for patients with diabetes melli- tus. Disease Management, 8(1), 15-25.
Oh, J.A., Kim, H.S., Yoon, K.H., & Choi, E.S (2003). A telephone-delivered interven- tion to improve glycemic control in type 2 diabetic patients. Yonsei Medical Journal, 44(1), 1-8
Orem, D.E. (1995). Nursing: Concepts of practice (5th ed.). St. Louis: Mosby.
Piette, J.D., Weinberger, M., McPhee, S.J., Mah, C.A., Kraemer, F.B., & Crapo, L.M. (2000). Do automated calls with nurse follow-up improve self-care and glycemic control among vulnerable patients with diabetes. The American Journal of Medicine, 108(1), 20-27.
The AGREE Collaboration. (2001). The appraisal of guidelines for research and evaluation (AGREE) instrument. Re – trieved from http://www.agreecollabora tion.org/pdf/agreeinstrumentfinal.pdf
The Diabetes Control and Complications Trial Research Group. (1993). The effect of intensive treatment of diabetes on the development and progression of long- term complication in insulin-dependent diabetes mellitus. The New England Journal of Medicine, 329(14), 977-986.
UK Prospective Diabetes Study (UKPDS) Group. (1998). Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes. The Lancet, 352(9131), 837-851.
Wong, F.K., Mok, M.P., Chan, T., & Tsang, M.W. (2005). Nurse follow-up of patients with diabetes: Randomized controlled trial. Journal of Advanced Nursing, 50(4), 391-402.
Additional Reading Sparacino, P. (2005). The clinical nurse spe-
cialist. In A.B. Hamric, J.A. Spross, & C.M. Hanson (Eds.), Advanced practice nursing: An integrative approach (3rd ed.) (pp. 416-435). St. Louis: Elsevier Saunders.
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