Running Head: UNCONTROLLED DIABETES
Uncontrolled Diabetes and Self-Efficacy in Nursing Practice
Stacy C. Holton
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Abstract
Proper management of diabetes mellitus through education and individualized care is essential to decrease the incidence of complications related to the disorder. Diabetes is a leading cause of health complications across the world and plays significant role in the rate of morbidity and mortality as well as accounts for a large portion of healthcare dollars spent. This paper is aimed at documenting specifically how the Theory of Self-Efficacy applies to diabetes management.
Self- Efficacy in diabetes management has been shown to improve patient self-care behaviors which are vital to effective diabetes management. Nurses play a vital role in the individualization of patient management plans which improve patient self-efficacy.

UNCONTROLLED DIABETES
Uncontrolled Diabetes, a Nursing Practice Problem
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Background
Diabetes mellitus is a metabolic disorder that causes hyperglycemia, which over an extended period of time leads to multiple debilitating and life threatening complications (Gray,
Drayton-Brooks & Williamson, 2013). These complications include blindness, amputations, cardiovascular and kidney disease as well as death (Gray et al., 2013). Control of hyperglycemia greatly decreases the risk of developing these complications. Lifestyle changes including diet modification and exercise implementation along with medication have shown the greatest improvement in outcomes for diabetic patients (Turkoski, 2006).
As of 2012 the American Diabetes Association recommends a glycosylated hemoglobin
(HgbA1c) less than 7% (McCarthy & Pearson, 2012). Poor diabetes management is a common problem globally. In the United States alone only 40-60% of patients have an HgbA1c level less than 7.5% ( Zafar, Davies, Azhar & Khunti, 2010). Many barriers to effective diabetic management exist and differ with each patient situation. Collectively these multiple barriers lead to a failure of diabetes management. Patient’s individual beliefs and cultural influence have been identified as influential factors. As well as poor communication with health care providers, low socio-economic status and lack of access to care. Health care professionals also contribute through mismanagement of medications and lack of aggressiveness of therapy. (Zafar et al.,
2010).
Nurses, due to their role as educators and their ability to individualize care to each patient are vital to improving outcomes of diabetic management (Spollett, 2003). According to a study conducted by Babwah (2011), patients that have nurses involved in their diabetic management

UNCONTROLLED DIABETES plans have significant improvements in glycemic control compared to patients managed by physicians only. This is thought to be related to nurse-patient relationships that are formed.
Relationships between nurses and patients increase time spent with patients discussing their health as well as improve participation in follow-up measures (Babwah, 2011).
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Education on diabetes management allowing for patient self-management of their disease is essential. Assessments to find out patients’ needs as well as health goals provide information so diabetic teaching and management goals can be tailored to each individual (Mayberry,
Willock, Boone, Lopez, Qin & Nicewander, 2010). In 2012 the American Diabetes Association updated the guidelines for diabetic management to include a patient-centered approach rather than the previously more standardized recommendations (McCarthy & Pearson, 2012). These changes resulted from the studies showing better outcomes with individualized care.
Problem Statement
Patients with uncontrolled diabetes have an increased risk of complications which can lead to debilitation and decreased quality of life. Lack of understanding of the disorder and decreased knowledge of management techniques increase these risks.
Significance
Diabetes is recognized as the seventh leading cause of death in the United States (Gray,
Drayton-Brooks & Williamson, 2013). As well as the number one cause of kidney injury, limb amputations not due to trauma and blindness in the adult population (Beechet & Appel, 2013).
The financial impact of diabetes around the world is estimated to account for 11.6% of healthcare dollars spent (Gray, Drayton-Brooks & Williamson, 2013). These statistics

UNCONTROLLED DIABETES 5 demonstrate the largely significant need for proper and effective diabetes management. Without effective diabetes management the problem will continue to grow.
The number of Americans diagnosed with diabetes is expected to rise. Some experts believe the incidence of diabetes could even double by the year 2050 (Robertson, 2012). An article by Zafar et al. (2010) stated that in 2007 the incidence of adults with diabetes worldwide was 246 million and by 2025 is expected to be 380 million. This increase will play an astronomical role in healthcare dollars spent as well as increase morbidity and mortality.
However, with an improvement in diabetes management through early intervention and tight glycemic control evidence states that improved quality of life and decreased complications are possible (Zafar et al., 2010).
Specific Aims
Individually, the goal of diabetes management is to decrease microvascular and macrovascular complications through an improvement in glycemic control (Gao, Wang, Zheng,
Harrdorger, Kegler, Zhu & Hu, 2013). This would include decreasing the incidence of retinopathy, renal dysfunction, neuropathy, coronary artery disease, stroke and peripheral artery disease (McCance, Huether, Brashers & Rote, 2010). On a large scale, the goals include decreased mortality and healthcare expenditures due to diabetic complications (Gao et al., 2013).
Diabetic outcomes have been shown to be related to self-care behaviors and self-efficacy in multiple studies (Gao et al., 2013). By improving self-care behaviors and patient’s selfefficacy it will improve glycemic control. Implementation of appropriate education on the disease process of diabetes, the known complications of the disorder and the proper interventions to achieve glycemic control leads to an improvement in self-care. Patients having a greater

UNCONTROLLED DIABETES understanding of their own health condition causes personal ownership. Furthermore, building
6 trusting relationships while individualizing their diabetic management plan will make them more accountable for their own self-care and improve their level of self-efficacy.
Theory/ Conceptual Framework/ Model
The Theory of Self-Efficacy is a middle range nursing theory that was developed by a social scientist, Bandura, with a basis in the social cognitive theory. Self-efficacy is “an individual’s judgment of his or her capabilities to organize and execute courses of action.”
(Resnick, 2014). The purpose of the Theory of Self-Efficacy is to show the relationship between person, behavior and environment. These three factors interact in a triadic reciprocal fashion, meaning they have an interrelationship versus being single factors that individually affect aspects of one’s judgment. In nursing practice the theory is used to identify reasons for human behavior related to an individual’s health (Resnick, 2014).
Bandura identified two major concepts in the theory, they include self-efficacy expectations and outcome expectations (Resnick, 2014). Self-Efficacy expectations are an individual’s beliefs of their own ability to accomplish a certain task. Outcome expectations are an individual’s beliefs of what will result if the given task is accomplished. Outcome expectations generally are effected by a person’s self-efficacy expectations (Resnick, 2014).
How well a patient believes they can accomplish the given task will affect the outcome they see for the future.
Bandura also stated four general sources through which individual’s normally acquire their judgment of self-efficacy. A person’s self-efficacy is influenced by enactive attainment, vicarious experience, verbal persuasion and physiological state or physiological feedback

UNCONTROLLED DIABETES mechanism (Resnick, 2014). The Theory of Self-Efficacy proposes that influences in an ideal
7 situation will increase one’s self-efficacy and outcome judgments in turn positively influencing the individual to accomplish the given task.
The Theory of Self- Efficacy has been used in multiple situations. Context for use is not clearly defined other than use is intended for areas where behavior change is necessary. Some areas were the Theory of Self-Efficacy has been previously applied are in health promotion activities including exercise and weight loss, symptom management, smoking cessation, management of chronic illnesses, and education for healthcare providers (Resnick, 2014).
Application of the Theory to Clinical Problem
The Theory of Self- Efficacy applies to the management of glycemic levels and complication prevention in diabetic patients. As stated previously self-efficacy is an individual’s belief that they can complete a given task (Resnick, 2014). In the case of diabetes, a patient needs to believe that they are able to manage their diabetes successfully in order to make the changes needed in their lifestyle and adhere properly to their medication regimen. Also, the patient needs a positive outcome expectation. This would include seeing the decreased incidence of complications and improved quality of life possible through proper diabetic management.
Multiple studies have shown that self-care behaviors are influential to glycemic control and selfefficacy is known to be a large factor in attaining proper self-care behaviors by patients (Gao et al., 2013).
In order for patients to be successful in the care of their diabetes they need to be efficient in certain skills. These skills include the ability to gather information, to monitor to their blood glucose levels individually on a regular basis and to adjust food and medication intake based on

UNCONTROLLED DIABETES stress, illness and activity level (McCleary-Jones, 2011). By implementing interventions of
8 increased education on the diabetic disease process and its management nurses have the ability to increase patient’s self-efficacy. Increased self-efficacy will then lead to improved glycemic control and a decrease in microvascular and macrovascular complications related to hyperglycemia.
Self- efficacy improvement has been shown to be successful in the management of chronic diseases other than diabetes as well. In a study by Shao, Chang, Edwards, Shyu & Chen
(2013) a twelve week educational self-management program was implemented for heart-failure patients. An improvement in self-care behaviors, self-efficacy of salt and fluid control and an overall decrease in heart failure related symptoms was seen in those patients that received the program related education (Shao et al., 2013). Although heart failure and diabetes do not have all the same management techniques, in both chronic diseases self-efficacy and self-care behaviors are essential to effective management.
Summary & Conclusions
In conclusion, the improvement of self-efficacy and self- management behaviors is essential to improving the problem of uncontrolled diabetes globally.
Nurse-patient relationships aimed at education and tailoring diabetic management plans to each individual have shown to improve glycemic control. By spending time educating patients on techniques used for effective diabetic management patient self-efficacy will improve. Areas shown to need an increase in patient education include the process of the disease and blood glucose monitoring along with diet and medication adaptation. This would lead to better outcomes for patients with diabetes including fewer complications and overall an improved quality of life.

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A significant reduction in healthcare expenditures would result from improvement of
9 diabetic management as well.
.By the year 2025, 380 million people could be suffering from diabetes and a proper management plan is needed to prevent known serious complications of the disorder. Application of the Theory of Self-Efficacy to diabetic management plans show that improvement of knowledge, self-care behaviors and self-efficacy are key. Nurses have the ability to change the future of healthcare and lessen the potential extreme impact that diabetes will play.

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