NURS 715 Week 6 Theory Guided Practice Paper Outline Example

Outline for a Theory Guided Practice Paper: Uncertainty and Self-Efficacy in a Patient Who Avoided Cardiac Rehabilitation

Working Thesis

This outline maps a paper whose thesis is that two forces kept Mr. Reyes out of the rehabilitation program: uncertainty he could not resolve about what his body was doing, and a lack of confidence that he could exercise safely. Neither theory alone explains his choice; uncertainty explains his fear, and self-efficacy explains why the fear became staying home. Mishel's theory, a nursing theory, explains the first force, and Bandura's self-efficacy theory, borrowed from psychology, explains the second. The paper will evaluate both theories with the same criteria and draw practice implications within a Christian worldview, and each point below names the source that will support it.

I. Introduction and Practice Experience

A. The experience

• 1. Mr. Reyes, 63, after an inferior myocardial infarction and one stent, referred to cardiac rehabilitation at discharge
• 2. Never attended; at a follow-up call he said he did not know if exercise was safe and feared every chest twinge
• 3. His father died suddenly at 60 of a heart attack
• 4. His wife was eager for him to attend but did not know what to tell him about his symptoms

B. Why this experience matters

• 1. Roughly half of referred patients at the writer's program never attend, so the case represents a common pattern

C. Purpose of the paper

• 1. Explain his avoidance with a nursing theory and a borrowed middle range theory
• 2. Evaluate both theories and draw implications within the Christian worldview

II. The Nursing Theory: Mishel's Uncertainty in Illness Theory

A. Origin and purpose

• 1. Developed from clinical observation and research; published in 1988 and reconceptualized for chronic illness in 1990 (Mishel, 1988, 1990)

B. Core concepts

• 1. Stimuli frame, structure providers and cognitive capacity as antecedents
• 2. Uncertainty appraised as danger or opportunity
• 3. Coping strategies leading toward adaptation

C. Key proposition for this paper

• 1. Unfamiliar, patternless symptoms without a trusted interpreter raise uncertainty; a danger appraisal produces avoidance

III. The Borrowed Theory: Bandura's Self-Efficacy Theory

A. Origin and purpose

• 1. From social cognitive psychology; self-efficacy is the belief in one's capability to carry out a behavior (Bandura, 1977)

B. Four sources of efficacy beliefs

• 1. Mastery experiences, the strongest source
• 2. Vicarious experiences of similar others
• 3. Verbal persuasion from credible people
• 4. Physiological and emotional states, interpreted

C. Why it is middle range in nursing use

• 1. A limited set of concepts focused on behavior change, widely measured with scales in cardiac populations

IV. Application of Each Theory to the Experience

A. Mishel applied

• 1. Unexplained twinges: a stimuli frame without pattern
• 2. No trusted clinician after discharge: a missing structure provider
• 3. Father's sudden death: inference driving a danger appraisal; avoidance as coping

B. Bandura applied

• 1. No mastery experience of safe exercise since the event
• 2. No contact with peers who had completed rehabilitation
• 3. Physiological arousal during exertion read as danger

C. How the theories connect

• 1. Uncertainty lowered his confidence and raised fear of activity, consistent with a 2026 chain mediation analysis in coronary disease (Wu et al., 2026)
• 2. Interventions can address both: explaining symptoms reduces uncertainty, and supervised sessions create mastery
• 3. Each theory supplies a measure: the uncertainty scale and an exercise self-efficacy scale, so a future project can test both pathways

D. Supporting evidence on self-efficacy

• 1. Among 305 psychologically distressed rehabilitation patients, each one-point rise in exercise self-efficacy was associated with about 13 more minutes of weekly activity at follow-up (Pollok et al., 2026)
• 2. A theory-based staged program improved exercise self-efficacy and reduced fear of movement in older adults with coronary disease (Zheng et al., 2026)

V. Evaluation of the Theories

A. Evaluation criteria

• 1. Substantive foundation, structural integrity and functional adequacy, the three criteria for middle range theory set out by Smith and Liehr (2014)
• 2. Each criterion judged for both theories with a stated reason and supporting evidence

B. Planned verdicts for Mishel

• 1. Foundation strong: practice-grounded, explicit assumptions
• 2. Structure sound but intricate; inference and illusion hard to separate
• 3. Function high: measurable, tested across many conditions

C. Planned verdicts for Bandura

• 1. Foundation strong: decades of research in many fields
• 2. Structure clear and parsimonious: four sources, one central concept
• 3. Function high: easy to translate into interventions and measures

VI. Implications Within the Christian Worldview

A. Uncertainty and trust

• 1. Scripture acknowledges human uncertainty about tomorrow while calling believers to trust God

B. Confidence and community

• 1. Encouragement from others as verbal persuasion; the church as a community of mutual support

C. Practice implications

• 1. The nurse as credible authority and encourager; respect for patients' own faith and fears

VII. Conclusion

A. Summary of the argument

• 1. The two theories together explain avoidance better than either alone

B. Next step for practice

• 1. A pre-rehabilitation call and tour designed from both theories, with uncertainty and self-efficacy measured

References

Bandura, A. (1977). Self-efficacy: Toward a unifying theory of behavioral change. Psychological Review, 84(2), 191-215. https://doi.org/10.1037/0033-295X.84.2.191

Mishel, M. H. (1988). Uncertainty in illness. Image: The Journal of Nursing Scholarship, 20(4), 225-232. https://doi.org/10.1111/j.1547-5069.1988.tb00082.x

Mishel, M. H. (1990). Reconceptualization of the uncertainty in illness theory. Image: The Journal of Nursing Scholarship, 22(4), 256-262. https://doi.org/10.1111/j.1547-5069.1990.tb00225.x

Pollok, V. L., Thome-Soós, F., Benninghoven, D., & Bethge, M. (2026). Influence of exercise self-efficacy on physical activity among psychologically distressed patients undergoing cardiac rehabilitation: Secondary data analysis of a randomized controlled trial. BMC Psychology, 14(1). https://doi.org/10.1186/s40359-026-04004-8

Smith, M. J., & Liehr, P. R. (Eds.). (2014). Middle range theory for nursing (3rd ed.). Springer Publishing.

Wu, L., Xue, H., Tian, C., & Lu, Y. (2026). Associations between uncertainty in illness and cardiac rehabilitation adherence in patients with CHD: A cross-sectional chain mediation and latent profile analysis of cardiac self-efficacy and fear of activity. Frontiers in Cardiovascular Medicine, 13, Article 1846950. https://doi.org/10.3389/fcvm.2026.1846950

Zheng, X., Tan, Y., Wang, X., Li, Q., Li, J., Lan, X., & Zhang, S. (2026). A randomized controlled trial of staged cardiac rehabilitation based on the Health Belief Model on kinesiophobia, self-efficacy and activities of daily living in elderly patients with coronary heart disease. Frontiers in Medicine, 13, Article 1857532. https://doi.org/10.3389/fmed.2026.1857532