DNP 751 Week 1 Revised Introduction, Background and Problem Statement Example

Section One, Second Draft: Introduction, Background and Problem Statement for a Proposal to Screen for and Respond to Diabetes Distress in Safety-Net Primary Care

[Student Name]

University of Phoenix

DNP/751: DNP Applied Project II

Week 1 Assignment: Proposal Section 1 Revision

[Instructor Name]

[Date]

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

Introduction

Every three months, adults with type 2 diabetes at our health center's east side site sit in an exam room while a medical assistant takes their blood pressure and hands them a tablet with questions about mood. The questions ask whether they have felt down or lost interest in things. None asks whether diabetes itself has become a burden: the finger sticks, the food rules, the fear of what comes next, the feeling of falling short at every visit. This proposal describes a quality improvement project to add that question, in validated form, and to make sure that an answer leads somewhere.

The site is one of three primary care locations of a federally qualified health center that serves a largely low-income, racially and linguistically diverse population in a mid-sized Midwestern city. It cares for 820 adults with type 2 diabetes. Four in ten have a most recent A1C above 9%.

Background

Diabetes distress refers to the worries, frustrations and sense of burden that arise from living with diabetes and managing it day after day. It is common across countries and health systems. In the second Diabetes Attitudes, Wishes and Needs study, Nicolucci et al. (2013) surveyed 8,596 adults with diabetes in 17 countries using validated measures and found that 44.6% reported diabetes-related distress, compared with 13.8% who met a threshold for likely depression, with wide variation between countries. Distress, in other words, was roughly three times as common as probable depression in the same people, yet most primary care screening in the United States is built around depression.

Distress also varies with the demands of treatment. In a primary care sample, Delahanty et al. (2007) found higher distress among patients treated with insulin than among those on oral agents or diet alone, largely explained by more severe disease and heavier self-care. Worry about the future and guilt when treatment went off track were among the most troubling items. For a site where many patients are moving onto insulin because of poor control, this points to a group likely to carry high distress.

The kind of distress matters for outcomes. Aikens (2012) followed 253 primary care patients with type 2 diabetes for six months and compared general depressive symptoms with diabetes-related distress as predictors. Depressive symptoms predicted later diet, activity and glucose testing, while only diabetes-related distress predicted later A1C and medication adherence. Earlier work by the developers of the Diabetes Distress Scale reached a similar conclusion about glycemic control (Fisher et al., 2010). Together these studies suggest that a site that screens only for depression may be missing the emotional factor most closely tied to the outcome it most wants to improve.

National guidance has caught up with this evidence. The American Diabetes Association standards now recommend routine monitoring for diabetes distress, with particular attention to people whose treatment goals are not being met, and they describe distress as distinct from depressive disorders (American Diabetes Association Professional Practice Committee, 2025).

Problem Statement

Adults with type 2 diabetes at one safety-net primary care site are screened for depression at 93% of eligible patients but are never assessed for diabetes distress, so a common condition linked with medication adherence and glycemic control goes unrecognized and unaddressed in routine diabetes care.

Purpose and Practice Question

The purpose of the project is to introduce distress screening with a follow-up pathway led by registered nurse care managers and to evaluate whether it raises identification and timely follow-up of distress and lowers distress over 12 weeks. The practice question, stated in full in the methods section, compares this pathway with depression screening alone among adults with type 2 diabetes at the site.

Significance to Nursing Practice

The project places a nursing role, care management, at the center of a psychosocial standard of diabetes care. Care managers already know these patients, carry their phone numbers and see the ones in poorest control. Giving them a validated way to hear distress and a menu of responses turns conversations that now end in frustration into structured follow-up. For the health center, the project tests a low-cost change that could spread to its other sites and support its federal diabetes control measure.

Definitions

Diabetes distress: the emotional burden of living with and managing diabetes, measured with the full Diabetes Distress Scale (17 items) and reported as the average of its items on a 1 to 6 range. Positive screen: an average of 3 or higher across the screener's two items. Eligible visit: a scheduled diabetes or chronic care visit, in person or by video, for an adult whose problem list records type 2 diabetes. Timely follow-up: a documented care manager contact, in clinic or by phone, no later than 14 days after a positive screen. High distress: a mean item score of 3.0 or more on the full scale.

Assumptions

The proposal rests on four assumptions. Patients will answer two questions about diabetes honestly when told the answers go to their own care team. Medical assistants can fit the screen into rooming without lengthening visits noticeably. Care managers can respond to most positive screens within their existing hours. And scores on the full scale will change over 12 weeks if patients receive structured attention, as they did in the trial evidence. Each assumption is tested by a measure in the evaluation plan, so a failed assumption will be visible rather than hidden.

Scope and Limits

The project covers one of the health center's three sites and adults with type 2 diabetes only. It does not change depression screening, medication management or diabetes education, which continue as they are. It cannot show that screening causes better glycemic control; 12 weeks is too short and the design has no randomized comparison. Its claims will be limited to whether distress is identified and followed up, and whether distress scores fall among patients who screen positive.

Organization of the Proposal

Section 2 synthesizes the literature on the prevalence, measurement, significance and treatment of distress. Section 3 presents the framework guiding implementation. Section 4 describes the design, setting, participants and procedures, Section 5 the implementation plan and timeline, and Section 6 the evaluation and analysis. Section 7 addresses ethics and approvals, and appendices hold the instruments, the site letter and the budget.

Revision Memo

Four changes were made in response to feedback on the DNP 750 precis. First, the background now includes international and primary care evidence rather than relying on the scale developers' studies. Second, the problem statement names the consequence, missed adherence and control problems, rather than stating only that screening is absent. Third, definitions were added so that each term matches a measure. Fourth, the introduction now describes the site in two sentences instead of a page, moving staffing detail to the setting section.

Summary

Diabetes distress is common, differs from depression and is tied to adherence and A1C. At the site, depression is screened well and distress not at all. The following section synthesizes the literature on detecting and reducing distress.

References

Aikens, J. E. (2012). Prospective associations between emotional distress and poor outcomes in type 2 diabetes. Diabetes Care, 35(12), 2472-2478. https://doi.org/10.2337/dc12-0181

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

Delahanty, L. M., Grant, R. W., Wittenberg, E., Bosch, J. L., Wexler, D. J., Cagliero, E., & Meigs, J. B. (2007). Association of diabetes-related emotional distress with diabetes treatment in primary care patients with type 2 diabetes. Diabetic Medicine, 24(1), 48-54. https://doi.org/10.1111/j.1464-5491.2007.02028.x

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

Nicolucci, A., Kovacs Burns, K., Holt, R. I. G., Comaschi, M., Hermanns, N., Ishii, H., Kokoszka, A., Pouwer, F., Skovlund, S. E., Stuckey, H., Tarkun, I., Vallis, M., Wens, J., & Peyrot, M. (2013). Diabetes Attitudes, Wishes and Needs second study (DAWN2): Cross-national benchmarking of diabetes-related psychosocial outcomes for people with diabetes. Diabetic Medicine, 30(7), 767-777. https://doi.org/10.1111/dme.12245