Integrating Nursing and Systems Theory into Patient-Centered Care

Effective chronic disease management requires evidence-based, patient-centered interventions that integrate nursing and systems theories. This paper examines a nurse-led self-management program for Type 2 diabetes (T2D), applying the Person-Centered Care Model (PCCM) and General Systems Theory (GST) to guide implementation, evaluation, and culturally competent care, demonstrating their impact on patient outcomes and healthcare efficiency: Integrating Nursing and Systems Theory into Patient-Centered Care.

Proposed Intervention: Nurse-Led Self-Management Program for Type 2 Diabetes

Based on the identified gaps and recommendations, effective management of T2D in adults will need to emphasize interprofessional practice and patient-centered care. The intervention plan for nurse-led self-management is comprised of teaching medication adherence, behavioral changes, and knowledge of glucose monitoring. It also has telehealth follow-up of behavioral coaching, EHRs, and a patient portal for real-time data acquisition and interactions with clients and providers.

This aligns with the current understanding of DM self-management because psychoeducation supports interpersonal changes, behaviors, and glycemic control and decreases complications (Dailah, 2024). The structured education and worksite digital health promote the organization, medication taking, self-confidence for participants, and satisfaction, and should be considered as a form of nursing intervention for chronic conditions.

Application of Theories to Guide the Intervention

Nursing Theory: Person-Centered Care Model (PCCM)

The Person-Centered Care Model (PCCM) emphasizes respect, dignity, shared decision-making, and holistic care, making it ideal for diabetes management. It ensures care is tailored to patients’ preferences, cultural beliefs, and lifestyle factors. Nurses prioritize patient-provider collaboration, enhancing self-management skills and health literacy.

PCCM aligns with Watson’s Theory of Human Caring, reinforcing compassion and trust. Incorporating patient perspectives improves engagement, adherence, and health outcomes through individualized support, culturally relevant education, and continuous monitoring, fostering better self-care and glycemic control (Robinson et al., 2021).

Systems Theory: General Systems Theory (GST)

Ludwig von Bertalanffy’s General Systems Theory (GST) views healthcare as an interconnected system where changes in one area affect the whole. In diabetes management, GST improves care coordination through digital tools, data sharing, and remote monitoring. Applying GST to a nurse-led intervention enhances efficiency by integrating EHRs and telehealth, allowing nurses to track progress and adjust care plans. GST also identifies barriers like socioeconomic factors and healthcare access, providing a systems-level approach to improving intervention effectiveness (Caws, 2024).

Theories as a Framework for Evaluating the Intervention

Assessment is necessary in order to ascertain the success of the intervention. PCCM is more patient oriented because it uses sources like satisfaction questionnaires, medication plan adherence, and self-efficacy enhancement. Therefore, positive changes including improved HL and increased self-efficacy in DM self-management point towards successful results.

From a systems perspective, sources of measure for evaluating the efficiency of intervention include: fewer hospital readmissions for patients, enhanced coordination of care, and utilization of technology. Monitoring the EHR utilization and telehealth access indicates whether the digital tools promote adequate interaction between the patient and the healthcare provider concerning the use of treatment regimens. Altogether, PCCM and GST provide a holistic point of pattern and end outcome as worthwhile either singularly or in partnership.

Application to Diverse Populations

PCCM and GST have components of culturally sensitive care that enhance minority health care delivery. The PCCM goals guarantee that education and support are given in accordance with cultural type preferences, health-related beliefs, and linguistic requirements. For instance, for patients with diabetes, educational resources can be disseminated and provided in different languages and at different levels of literacy.

Following this, GST takes the problem of diversity-focused care a step forward by combating systematic issues like financial issues, accessibility to healthcare, and other inequalities, as well as limited proficiency with technology. To reach out to these groups of patients, the intervention could join forces with community partners and social support initiatives and engage in policy development. Also, diverse employees and culturally competent care increase patient involvement.

Conclusion

Transforming the existing components of the PCCM model and adopting elements of the GST approach into a nurse-led self-management program for Type 2 diabetes patients improves patient-centredness, system improvement, and those of the patient. PCCM creates comprehensive and patient-centered models of care while GST focuses on organization and technology in care delivery. Collectively, these theories offer a sound guideline to developing, implementing and assessing the outcomes of nursing interventions that will offer effective and culturally sensitive healthcare services.

References

Caws, P. (2024). General Systems Theory: Its Past and Potential. Systems Research and Behavioral Science, 32(5), 514–521. https://doi.org/10.1002/sres.2353

Dailah, H. G. (2024). The Influence of Nurse-Led Interventions on Diseases Management in Patients with Diabetes Mellitus: a Narrative Review. Healthcare, 12(3), 352. https://doi.org/10.3390/healthcare12030352

Robinson, S. K., Meisner, M., Robert L., Phillips, J., & McCauley, L. (2021). Person-Centered, Family-Centered, and Community-Oriented Primary Care. In www.ncbi.nlm.nih.gov. National Academies Press (US). https://www.ncbi.nlm.nih.gov/books/NBK571814/

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Purpose:
The purpose of this assignment is intended to allow the student to show evidence of the following course objectives:

• Explain how the advanced practice nurse applies and integrates broad, organizational, client-centered, and culturally appropriate concepts in the planning, delivery, management, and evaluation of evidence-based clinical prevention and population care and services to individuals, families, and aggregated/identified populations.
• Explain how the advanced practice nurse applies and integrates broad, organizational, client-centered, and culturally appropriate concepts in the planning, delivery, management, and evaluation of evidence-based clinical prevention and population care and services to individuals, families, and aggregated/identified populations.
• Apply theory and research-based knowledge from nursing, the arts, humanities, and other sciences

Description:

• Students will write a paper applying and integrating the information written about the concept map you have worked on throughout the course.
  • You should finalize the concept map by identifying and discussing a nursing theory and a systems theory to an appropriate clinical practice situation common to advanced nursing care.
  • You will also need to select an appropriate nursing intervention that would aid in using the selected theories to demonstrate appropriate applications of the nursing theories. It is strongly recommended you use the nursing theory previously identified for the Concept Map assignment.
  • You will be adding a systems theory to this final paper. The paper will demonstrate how systems theory and nursing theories are used in the design, delivery, and evaluation in healthcare.
  • Students will also evaluate how these theories can be utilized to deliver care to diverse populations.
• See the attached rubric for grading details.
  

  Integrating Nursing and Systems Theory into Patient-Centered Care

Requirements:

• This assignment is due by Day 5 (Sunday) at midnight EST and must be added to Canvas on the date assigned unless you have made different arrangements with your instructor prior to the beginning of class on that day. Failure to meet these requirements will result in a grade of zero (0) for that course assignment.
• This assignment needs to be submitted following APA format (title page, headings, reference page, etc.). Citations from References that are synthesized from the assigned article, course text, evidence-based and peer-reviewed research articles, and other credible sources are required. A minimum of 3 resources are used. References must be current within 5 years.
• This assignment will be submitted below through Canvas and automatically run through TurnItIn. Course faculty monitor for the compliance of citations with Turnitin evaluation of the assignment during the course session. If your originality score is above 10-15%, check to make sure that all similarities are properly cited and/or go back and paraphrase to lower your percentage. You may resubmit your paper if needed, however, keep in mind that it may take 24 hours for your second attempt to be scored, which would affect your ability to turn your paper in on the due date. My advice would be to try to submit the paper a day or two early to allow time to resubmit if needed.
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NOTE: Evidence of plagiarism will result in a score of 0 for this assignment. Repeat offenses of plagiarism will result in more significant repercussions per the South College student handbook.