Introduction: Problem and Context
Type 2 diabetes (T2D) is a prevalent issue among the US population. According to the estimates provided by the Centers for Disease Control and Prevention (CDC, 2020), 34.2 million people, which is 10.5% of the population of the US, had diabetes in 2018, and the incidence of T2D has significantly increased over time. Older adults are at a higher risk of developing diabetes. Statistics show that the prevalence of diagnosed and undiagnosed diabetes among people aged 18-44 is 4.2%, while in adults aged 65 and older, this percentage is 26.8% (CDC, 2020). Men are slightly more likely to have diabetes, and, among different races, Black individuals are at an increased risk of developing the condition (CDC, 2020). T2D is a serious problem because it may lead to the development of complications if it remains uncontrolled, thus threatening patients’ well-being and quality of life and burdening the healthcare system.
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The clinical scenario to be addressed in this paper involves a college-educated retired 68-year-old man having a 4-year history of T2D. At the time when he was diagnosed, he had a fasting blood glucose level of 119-128 mg/dl and was advised to lose weight, but the patient took no action. Currently, the patient is referred to the diabetes clinic by his family physician. The patient has a weight gain of 22 lb., and his blood glucose levels are controlled by medications. Although he tried to lose weight during the past six months and increase his physical activity levels, these attempts were without success. Before retirement, the patient had his own business, and after retiring, the patient has been active in volunteer organizations. He has been married for 43 years and has two adult married children. After retirement, he has also become more physically active, occasionally gardening and playing golf. His dietary history shows an excessive intake of carbohydrates in the form of pasta and bread. The patient also reports eating more and more often whenever he feels stressed.
In this scenario, the area that can be targeted by nurses is patient education about the behavior change necessary for effective self-management of diabetes. According to van Ommen et al. (2018), the burden of lifestyle-related diseases such as diabetes would decrease for both patients and the healthcare system if patient care for such diseases would be directed toward establishing an “optimal” lifestyle (p. 2). A wrong diet and insufficient physical activity are among the leading factors that make individuals susceptible to T2D (Van Ommen et al., 2018). Therefore, nurses should focus on encouraging patients’ behavior change to improve their health outcomes. This paper aims to apply a theory to guide nursing practice in providing care to diabetes patients. First, it will review how the transtheoretical model and Johnson’s behavior system model pertain to the issue of diabetes. Further, the paper will apply Johnson’s theory to the clinical issue to guide practice improvement. The behavior system model appears to be a suitable framework for directing nursing practice in diabetes management because it adopts a systems approach to care and provides clear guidance for clinical practice.
Theory Description and Critical Reflection
Two Theories Pertaining to the Issue
The first theory pertaining to the issue of diabetes management is the transtheoretical model (TTM). It is a borrowed theory, meaning that it does not originate in the nursing field but is nevertheless useful in the clinical context. The key element of TTM is the stages of change which reflect different degrees of people’s readiness to change their behaviors (Butts & Rich, 2017). This theory was developed by Prochaska and colleagues and includes five stages of change, which do not necessarily follow each other in a sequence; rather, they can be repeated (Butts & Rich, 2017).
The first stage in TTM is pre-contemplation, during which individuals do not think about a lifestyle change. In diabetes patients, this stage may occur in those who have just been diagnosed with diabetes and do not know that they need to change their lifestyles. The second stage is contemplation, which involves thinking about change. It occurs when patients have been educated about the need for change. The third stage is preparation for change, and, in diabetes patients, it is often linked to individuals’ choices between new and old behaviors, such as eating healthily or following their food preferences (Nor et al., 2021). The fourth stage is action, which involves adopting new habits, and the fifth stage is maintenance. According to Nor et al. (2021), the maintenance phase in diabetes patients begins when they have been following new behavior patterns for six months and longer. This theory pertains to the issue of diabetes management because it explains how people progress from not knowing about the need for change to sustaining behavioral change. It takes into consideration people’s inner resistance to change and the possibility of a relapse. TTM can guide nursing practice in diabetes management by helping them identify patients’ preparedness for change and develop interventions accordingly.
The second theory is Johnson’s behavioral system model. It is a nursing theory that posits that the main nursing goal is to restore and maintain the balance in the behavioral system (Butts & Rich, 2017). Johnson’s theory sees a patient as an open behavioral system comprised of seven subsystems interacting with each other. According to Johnson, the nurses’ role is to assess the patient’s subsystems and their stability and balance; whenever a subsystem imbalance is detected, nurses should restore and maintain the balance in the behavioral system (Butts & Rich, 2017). This theory pertains to the issue of diabetes management because it guides the nursing process of patient assessment and helps identify unhealthy behaviors that should be changed to improve patient outcomes. It also assists nurses in determining the focus of care in a particular patient and outlines health outcomes that should be achieved as a result of care.
Selected Theory and the Rationale for Selection
The theory selected for the presented scenario is Johnson’s behavior system model. The rationale for the choice of this model is that it views a patient as a system in which different biological and behavioral components are interrelated and influence each other. Such a view is important for diabetes management because this disease requires a systems intervention for the results of patient care to be effective (Van Ommen et al., 2018). According to Van Ommen et al. (2018), diabetes care should address biological, psychological, social, and spiritual domains because factors affecting the patient’s health outcomes include not only metabolic status but also dietary preferences, peer pressure, and worldview, among others. Thus, Johnson’s theory appears to be appropriate for this issue because it helps identify the factors influencing the patient’s well-being and address them using a systems approach.
Description and Critical Reflection
The behavior system model was developed by Dorothy Johnson, an American researcher, nurse, and author of many articles, books, and reports. The purpose of Johnson’s theory is to “clarify the social mission of nursing” since she believed that the nursing profession made a significant contribution to the well-being of society (Holaday, 2021, p. 270). The major concepts of this theory are a person, environment, health, and nursing. A person is defined as a behavioral system comprising seven behavioral subsystems (Butts & Rich, 2017). The environment is understood as forces that can upset the behavior system’s balance and threaten its stability (Butts & Rich, 2017). Health in this theory is determined by “the interaction of various psychological, social, biological, and physiological factors” (Butts & Rich, 2017, p. 402). Finally, nursing is defined as an “external regulatory force” acting to preserve the optimal level of patient behavior (Butts & Rich, 2017, p. 402). Thus, according to this theory, the patient in the presented scenario is viewed as a behavioral system whose internal and external environment, which includes, for example, diet, exercise, and social support, affects his health outcomes. The goal of nursing, in this case, is to identify any imbalances in the patient’s behavioral system and restore the balance.
The nature of the relationships in this theory is that nursing should be concerned with the relationship between the patient and the environment rather than the patient and the disease (Holaday, 2021). The theory has a clear structure: it views a patient as a behavioral system that consists of seven subsystems, which include “achievement, affiliative, aggressive, dependence, sexual, eliminative, and ingestive subsystems” (Butts & Rich, 2017, p. 398). These subsystems include four structural elements: goal or drive, set, choice, and behavior or action (Butts & Rich, 2017). The drive means the motivation for certain behavior. The set refers to the patient’s preferred behaviors directed toward meeting the goal. The choice means the available options for meeting the subsystem’s goal. The behavior is the only directly observed component that results from the three previous ones, and nurses should assess whether this component effectively meets the subsystem goal.
The behavioral system model developed by Johnson builds on four assumptions. First, it assumes that behavior is the sum of social, biological, and physical factors. Second, it sees a person as a behavior system that always aims to achieve balance. Third, levels of stabilization and balance are different and vary over time. Fourth, individuals spend much energy on maintaining or restoring the behavior system balance. In the presented scenario, the patient’s health condition is influenced by various factors, ranging from blood glucose levels to diet and social support. His level of balance decreased over time, which led him to present to the diabetes clinic with the purpose of losing weight. According to the theory, the nurses’ goal, in this case, is to help the patient restore the balance in his subsystems.
Johnson’s theory is simple because it involves a relatively small number of major concepts and describes each of them in detail. The theory is clear because its concepts are clearly defined, and its comprehensiveness is adequate for guiding nursing research, practice, administration, and education (Butts & Rich, 2017). The model is general since it has almost limitless applicability for ill persons; however, it is less applicable to healthy individuals and is not intended for preventive nursing (Butts & Rich, 2017). Since the concepts of the theory are consistently defined, it possesses a high degree of accessibility (Holaday, 2021). Finally, Johnson’s theory is highly important because it guides nursing practice, research, and education.
Clinical Practice Improvement Model
The clinical practice improvement model chosen for this case is the AADE7 Self-Care Behaviors framework. This model was developed by the American Association of Diabetes Educators (AADE, 2020) for guiding healthcare teams in goal-setting and person-centered collaboration to attain patients’ behavior change leading to improved health outcomes and quality of life. It is an evidence-based framework for assessing and delivering interventions for individuals and populations with diabetes and various cardiometabolic conditions (AADE, 2020). The model consists of seven self-care behaviors: healthy coping, healthy eating, taking medication, being active, reducing risk, monitoring, and problem-solving (AADE, 2020). Healthy coping is the core of the model; it refers to positive attitudes toward diabetes self-management, and without it, a sustainable behavior change cannot occur. Being active, healthy eating, and taking medication are healthy behaviors that build on the core of the model and are the basis for care plans. Monitoring refers to tracking the mentioned healthy behaviors by recording blood glucose level, weight, caloric intake, medication, and activity. Finally, problem-solving and reducing risks are based on the data collected during monitoring.
The rationale for the choice of this model is that it is evidence-based and covers different aspects of diabetes care aimed at encouraging and sustaining patients’ behavior change. The AADE7 framework provides a self-care plan for individuals with diabetes and guides behavioral, educational, and clinical assessment for healthcare professionals (AADE, 2020). The application of this model in educating patients about diabetes has been shown to improve patients’ knowledge and skills of diabetes self-management, as well as A1C levels (Miller, 2020). Therefore, this framework appears to be effective for changing patients’ behaviors related to diabetes self-care, thus improving their health outcomes.
Application of Theory to Practice
Clinical Issue Assessment in Terms of the Theory
Using Johnson’s theory, a nurse will assess the patient from the scenario by obtaining information about the patient’s past behavioral patterns and the influence of diabetes on his behavior. The assessment will focus on evaluating the structure and functions of the behavioral subsystems and the environmental factors that affect them (Holaday, 2021). Regarding the achievement subsystem, the nurse will reveal that the patient met many development goals of adulthood. As for the attachment-affiliative subsystem, the patient is married, has good relationships with his adult children, and is socially active in volunteer organizations. Regarding the aggressive-protective subsystem, the patient sees his weight gain as a threat to his health and wants to resolve this problem. The assessment of the dependency, sexual, and eliminative subsystems shows that they are not affected by the disease. However, the nurse will find that his ingestive subsystem negatively influences all other subsystems, so it can become the focus of care. The patient’s environment does not seem to aggravate his behavioral system’s imbalance since he lives in a suburban neighborhood with his wife, is socially active, and has an opportunity to engage in physical activity.
The nurse will also have to assess the structural components of subsystems, which include drive, set, choice, and actions (Holaday, 2021). Regarding the drive, the patient appears motivated to take the necessary diagnostic tests and follow healthcare recommendations. As for the set, the patient is accustomed to making his own decisions. Regarding the choice, the patient agrees to diagnostic tests, seeks assistance in managing weight, and has attempted to lose weight on his own. As for the actions, the patient’s behavior is not quite effective for managing diabetes because his diet is imbalanced, and his physical activity is sporadic. Nursing interventions should be directed toward restoring the balance of the behavioral system and identifying actions that will enhance healthy behaviors leading to the system’s stability and balance (Holaday, 2021). In this case, the nurse should focus on the ingestive subsystem, which causes the system imbalance.
Plan for Practice Improvement
The first step in addressing the clinical practice issue of diabetes management will be to gather support. This is consistent with the health coping element of the AADE7 model since having support from family, healthcare workers, and friends enhances positive attitudes toward diabetes management and improves patients’ self-efficacy (AADE, 2020). Gathering support is also consistent with Johnson’s theory as it posits that behavior includes not only physical and biological but also social factors (Butts & Rich, 2017). The following step will be to introduce a dietary intervention. It would be consistent with Johnson’s theory because it will target the patient’s ingestive subsystem, which, according to Johnson, refers to “when, how, what, how much, and under what conditions we eat” (Butts & Rich, 2017, p. 399). Diet change is a significant part of the AADE7 framework, and it involves such actions as creating a personalized meal plan, measuring portions, monitoring intake, and understanding the nutrition facts label (AADE, 2020). In the presented case, nurses should act as an external regulatory force (Holaday, 2021). For example, nurses can identify the patient’s ineffective responses to stressors and teach him to deal with stress in ways other than eating.
Expected Outcomes and Evaluation Criteria
Consistent with the theory, the expected outcome will be the restored balance among the subsystems. According to van Ommen et al. (2018), chronic calorie restriction leads to maintained weight loss, which, in turn, reduces HbA1c, blood pressure, and lipoprotein levels. Nurses will evaluate the outcomes by comparing the pre-intervention condition of the ingestive subsystem and its influence on other subsystems with its condition after treatment. In particular, evaluation criteria should include measuring the patient’s weight and HbA1c levels.
Johnson’s behavioral system model appears to be appropriate for guiding diabetes care because it views a person as a behavior system that strives toward balance. In diabetes management, a systems approach is crucial because patients’ health outcomes depend on different aspects of patients’ behaviors, including diet, physical activity, medication adherence, and social support. In the given case, Johnson’s theory has helped identify the imbalance in the patient’s ingestive subsystem, which negatively influenced the patient’s health. Therefore, one strength of this theory pertaining to the described clinical issue is that it allows nurses to assess patients’ behavior and detect any ineffective patterns that negatively affect their well-being. Another strength of Johnson’s theory is its clarity and simplicity since all major concepts in it are clearly defined and described in detail. One weakness of this model pertaining to diabetes care is that it is not applicable to preventing diabetes in the population at risk.
American Association of Diabetes Educators. (2020). An effective model of diabetes care and education: Revising the AADE7 self-care behaviors®. The Diabetes Educator, 46(2), 139-160.
Butts, J. B., & Rich, K. L. (2017). Philosophies and theories for advanced nursing practice (3rd ed.). Jones & Bartlett Learning.
Centers for Disease Control and Prevention. (2020). National diabetes statistics report 2020: Estimates of diabetes and its burden in the United States.
Holaday, B. (2021). Dorothy Johnson: Behavioral system model. In M. R. Alligood (Ed.), Nursing theorists and their work (10th ed., pp. 270-288). Elsevier Health Sciences.
Miller, R. S. (2020). Effectiveness of a diabetes education intervention in a faith-based organization utilizing the AADE7. ADCES in Practice, 8(1), 10-14.
Nor, N. M., Sidek, S., Saad, N., Jaafar, N. H., & Mohd Shukri, N. A. (2021). Adhering to lifestyle change recommendations via the trans-theoretical model: A mixed-methods study among type 2 diabetes patients. Nutrition & Food Science, 51(2), 362-374.
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