DNP 750 Week 1 Practice Problem and Local Significance Example

More Than One in Three and Never Asked: Unrecognized Diabetes Distress in a Safety-Net Primary Care Site's Type 2 Diabetes Panel

[Student Name]

University of Phoenix

DNP/750: DNP Applied Project I

Week 1 Assignment

[Instructor Name]

[Date]

The health center, staff and figures are composites written for a model paper.

Last spring a woman of 58, eleven years into life with type 2 diabetes, told me during a routine visit that she had stopped checking her blood sugar because each number felt like a judgment. Her A1C had been above 9% for two years. Her annual depression screen, completed at the front desk, had been negative every time. Nothing in our workflow had asked about the feeling she described. This paper identifies the practice problem behind her visit, shows its significance nationally and at my site, and states the problem that my DNP applied project will address.

The Practice Site

I practice as a family nurse practitioner at one of three primary care sites of a federally qualified health center in a mid-sized Midwestern city. The site serves about 6,400 adults a year, 68% of whom are covered by Medicaid or are uninsured, and 820 of whom have a diagnosis of type 2 diabetes. The care team includes four nurse practitioners, three physicians, two registered nurse care managers, five medical assistants and one licensed clinical social worker who serves as behavioral health consultant for the site.

Defining Diabetes Distress

Diabetes distress is the emotional response to the demands of living with diabetes: worry about complications, frustration with the regimen, feeling unsupported by clinicians or family, and the sense of failing at self-management. Polonsky et al. (2005) developed the 17-item Diabetes Distress Scale by testing items with patients at four clinical sites and found four consistent domains, emotional burden, physician-related distress, regimen-related distress and interpersonal distress, with good internal reliability. The scale separated a condition that clinicians had often folded into depression.

Distress Is Not Depression

The distinction matters for practice. Fisher et al. (2010) followed adults with type 2 diabetes and compared three measures: major depressive disorder, depressive symptoms and diabetes distress. Only diabetes distress was linked with A1C, both at a single point and as the two changed together over time; neither major depression nor depressive symptoms showed that link. Depression screening, which our site performs well, therefore cannot stand in for distress screening. A patient can screen negative for depression while struggling with exactly the distress that undermines self-care, as the patient I described had done.

National Significance

Perrin et al. (2017) pooled 55 studies with nearly 37,000 people with type 2 diabetes and estimated the prevalence of diabetes distress at 36%, higher in samples with more women and more depressive symptoms. Applied to our site, that estimate suggests about 295 of our 820 patients carry clinically relevant distress. In its current standards, the American Diabetes Association Professional Practice Committee (2025) recommends that clinicians screen people with diabetes for distress routinely, particularly when treatment goals are not met or when complications begin, and to address distress or refer when it is found. Distress is thus a recognized, common and measurable condition with a practice standard behind it.

Local Significance

Our site's data show the gap directly. In the past year, 93% of adults with type 2 diabetes had a documented depression screen with the PHQ-9 or its two-item version. No patient had a documented diabetes distress screen, because no distress tool exists in our electronic health record. Forty-one percent of our diabetes panel had a most recent A1C above 9%, compared with the health center's goal of under 30%, and 22% missed two or more scheduled diabetes visits. Care managers told me that they often suspect distress but have no structured way to raise it or a pathway once it is named.

Consequences of the Gap

Unrecognized distress has costs for patients and the site. For patients, distress is associated with poorer self-care and higher A1C, and it can lead to missed visits and disengagement. For the site, the health center reports diabetes control as a quality measure under its federal grant, and poor control affects performance on that measure. For clinicians, repeated visits that intensify medication without addressing the patient's emotional barriers are frustrating and often unproductive.

Why a Nursing Practice Problem

The gap is a process problem within reach of a nurse-led change. Screening tools are short, care managers already see these patients, and the behavioral health consultant is on site. The problem does not require new research to establish that distress exists or matters; it requires translation of existing evidence into a workflow. That is the work of a DNP-prepared nurse: identifying a gap between evidence and practice, designing a change, leading the team through it and evaluating the result.

Why This Problem Now

The timing is favorable for three reasons. The health center is replacing its annual depression screening form this year, which opens a place in the workflow. The behavioral health consultant has capacity for about eight new referrals a week. Leadership has named diabetes control as its top quality priority for the coming grant year.

Scope and Feasibility

The project will be limited to adults with type 2 diabetes at my site, rather than all three sites, so it can be completed within the applied project courses. It will address identification and follow-up of distress, not the treatment of depression or diabetes medication management, which have existing processes.

Problem Statement

At one federally qualified health center primary care site, adults with type 2 diabetes are routinely screened for depression but never for diabetes distress, a condition present in about a third of this population and linked with poor glycemic control, so distress goes unrecognized and unaddressed during diabetes care.

What Patients and Staff Describe

Before writing this paper I asked both care managers to keep a two-week log of visits in which a patient with type 2 diabetes described frustration, guilt or exhaustion related to the disease. They recorded 19 such conversations in 71 contacts. In most, the care manager listened and moved on to medication or diet teaching, because no tool or plan existed for what the patient had said. One care manager wrote that she hears the same sentence, "I'm tired of this," several times a week and has nowhere to document it. The log is not a measure of prevalence, but it shows that distress is already surfacing at the site and being lost.

Equity Considerations

The site's patients carry burdens that can deepen distress: food insecurity, unstable work hours, costly supplies and, for some, care in a second language. The estimate from Perrin et al. (2017) came mostly from studies in higher-income settings, so the true share at a safety-net site may be higher. Spanish-speaking patients, 14% of the panel, receive the depression screen in Spanish but would have no distress tool in any language. A problem statement for this site must therefore include every patient on the panel, and the project will need translated materials and interpreter time from the start.

Conclusion

Diabetes distress is common, distinct from depression and tied to glycemic control, and national standards call for routine screening. At my site, none of the 820 adults with type 2 diabetes has been screened for it, while four in ten have an A1C above 9%. This gap between evidence and practice is specific, measurable and within the reach of a nurse-led project. Next week I will turn the problem statement into a purpose statement and a practice question.

References

American Diabetes Association Professional Practice Committee. (2025). 5. Facilitating positive health behaviors and well-being to improve health outcomes: Standards of care in diabetes 2025. Diabetes Care, 48(Suppl. 1), S86-S127. https://doi.org/10.2337/dc25-S005

Fisher, L., Mullan, J. T., Arean, P., Glasgow, R. E., Hessler, D., & Masharani, U. (2010). Diabetes distress but not clinical depression or depressive symptoms is associated with glycemic control in both cross-sectional and longitudinal analyses. Diabetes Care, 33(1), 23-28. https://doi.org/10.2337/dc09-1238

Perrin, N. E., Davies, M. J., Robertson, N., Snoek, F. J., & Khunti, K. (2017). The prevalence of diabetes-specific emotional distress in people with type 2 diabetes: A systematic review and meta-analysis. Diabetic Medicine, 34(11), 1508-1520. https://doi.org/10.1111/dme.13448

Polonsky, W. H., Fisher, L., Earles, J., Dudl, R. J., Lees, J., Mullan, J., & Jackson, R. A. (2005). Assessing psychosocial distress in diabetes: Development of the Diabetes Distress Scale. Diabetes Care, 28(3), 626-631. https://doi.org/10.2337/diacare.28.3.626