Compliance, Motivation and Health Behaviors of the Learners

The nurse as educator of patient, client, or student needs to understand what drives the learner to learn and what factors promote or hinder the learning process. Motivation and compliance are concepts that are utilized in several health behavior models. The learner’s level of motivation can indicate potential involvement in health education programs. Sands and Holman (1985) noted that compliance often has been used by researchers as a measure of outcomes of these programs. Becker et al (1974) found motivation to be significantly related to measure of compliance with a medical regimen. Factors that determine health outcomes are complex. Ross and Rosser (1989) indicated that information alone does not account for changes in health behavior. Knowledge alone does not guarantee that the learner will engage in health-promoting behaviors or attain desired outcomes. The most well-thought-out educational program or plan of care will not achieve the desired goals if the learner is not understood in the context of factors associated with motivation and compliance. An understanding of the relationship between receiving information and the application of information, as well as those factors that impede or promote desired health outcomes, is essential for the nurse as a patient educator. Compliance The word ‘compliance’ comes from the Latin word “complire”, meaning to fill up and hence to complete an action, transaction, or process. Compliance is a patient's or doctor's adherence to a recommended course of treatment; hence, it describes the submission or yielding to predetermined goals. It has a manipulative or authoritative undertone in which the healthcare provider is viewed as the traditional authority and the learner or patient is viewed as submissive. This term has not been well received in nursing, perhaps due to the philosophical perspective that clients have the autonomy to make their own healthcare decisions and to not necessarily follow established courses of action as set by healthcare providers. Healthcare literature suggests that compliance is the equivalent of achieving a goal based on a planned regimen. Compliance is different from motivational factors, which are viewed as means to an end. Compliance to a health regimen is an observable behavior and as such can be directly measured. Motivation, on the other hand, is a precursor to action that can be indirectly measured through behavioral consequences or results.

Commitment or attachment to a regimen is called as adherence, which may be longlasting. Both compliance and adherence refer to the ability to maintain health-promoting regimens, which are determined largely by a healthcare provider. It is possible for an individual to comply with a regimen and not necessarily be committed to it. Both compliance and adherence are terms used in the measurement of the health outcomes. Perspectives on Compliance Eraker et al (1984) and Levanthal et al (1987) described theory of compliance that can be viewed from various perspectives and are useful in explaining or describing compliance from a multidisciplinary approach including psychology and education. The following are the theories described: 1. Biomedical theory a. It includes patient’s demographics, severity of disease and complexity of treatment regimen. 2. Behavioral / Social Learning theory a. Using the behaviorist approach of reward, cues, contracts and social supports 3. Communication feedback, loop of sending, receiving, comprehending, retaining, and acceptance 4. Rational belief theory a. It weighs the benefit of the treatment and the risks of disease through the use of cost-benefit logic 5. Self-regulatory systems a. Patients are seen as problem solvers whose regulation of behavior is based on perception of illness, cognitive skills and past experiences that affect their ability to plan and cope with illness. Locus of Control The authoritative aspect of compliance infers that the educator makes an attempt to control, in part, decision making on the part of the learner. Some models of compliance have attempted to balance the issue of control by using terms such as mutual contracting (Steckel 1982) or consensual regimen (Fink, 1976). The concept of locus of control (Rotter, 1954) or

health locus of control (Wallson et al 1978) is one of the ways to view the issue of control in the learning situation. Through the objective measurement, individuals can be categorized as internals, whose health behavior is self-directed, or externals, whereby others are viewed as more powerful in influencing health outcomes. External believe that fate is powerful external force that determines life’s course, whereas internals believe that they control their own destiny. Locus of control has been linked to compliance with therapeutic regimens. Hussey and Giolloland (1989) note that both locus and control and functional literacy level influence compliance. Functional literacy level in relation to compliance also needs to be assessed by the nurse. Shiilinger (1983) suggests that different teaching strategies are indicated for internals and externals. The literature, however, remains inconclusive as to the nature of the relationship between compliance and internal versus externals. Noncompliance Noncompliance describes resistance of the individual to follow a predetermined regimen. Ward and Collins (1998) notes that noncompliance can be highly subjective judgmental term sometimes used synonymously with non-cooperative or disobedient. She suggests the elimination of the term from professional vocabulary. The literature is replete with studies that indicate patient noncompliance. Nevertheless, the question of why clients are noncompliant remains largely unanswered. The educator’s self-awareness relative to the learner’s personality characteristics and previous history of compliance to health regimen could play an important role in the educational process. In an overview of the nursing literature reported by Russell, Daly, Hughes and Hoog (2003) noncompliance was categorized as follows: 1. A patient problem to be solved by nursing interventions 2. Rationalization – critical of the term noncompliance but acknowledges its importance in healthcare issues. 3. Evaluative – expresses concern about the term but offers various perspectives. Russel et al note that the “labeling of the noncompliance is predominantly based on nurses’ opinions of patient’s behavior” (2003). The result of this intervention, rationalization, and evaluative review support a patient-centered approach that challenges nurses not to reeducate, or coerce, but rather to embrace a paradigm shift that changes patient’s lives rather

He noted that if avoidance endured in an approach-avoidance conflict. and many motives can be involved in one behavior. They conclude that nurses need to act as advocates and acknowledge the importance of patient’s self-knowledge and decision making. conceptualized motivation in terms of positive or negative movement toward goals. Viewed in this way. noncompliance is not an obstacle to learning and does not carry a negative connotation. Using the hierarchy of needs . however. It is also described as a willingness of the learner to embrace learning. Motivation The word motivation comes from the Latin word “movere” that means to set in motion. The major premises of Maslow’s motivation theory are integrated wholeness of the individual and a hierarchy of goals. The learner may use time-outs as the intensity of the learning situation is maintained or escalates. with readiness as evidence of motivation. the learner could reengage. At times. motivation is the result of both internal and external factors and not the result of the external manipulation alone. feeling renewed and ready to continue with an educational program or regimen. is generally not a serious consideration in motivational models of health behavior or motivational research. Ideally. motivation is defined as the psychological force that moves a person toward some kind of action. Following withdrawal. noncompliant behavior may be desirable and could be viewed as a necessary defensive response to stressful situations. the nurse educator’s role is to facilitate the learner’s approach toward a desired goal and to prevent untimely delays. there would be negative movement away from a goal. He noted that not all behavior is motivated and that behavior theories are synonymous with motivation. Once an individual’s equilibrium is disturbed. According to Kort (1987). The expectation of total compliance in all spheres of behavior and at all times is unrealistic. This time factor. forces of approach and avoidance may come into play.than health outcomes. Many determinants of behavior other than motives exist. Lewin. Implicit in motivation is movement in the direction of meeting a need or toward reaching a goal. This mechanism of temporary withdrawal from the learning situation may actually prove beneficial. a field theorist. Maslow developed a theory of human motivation that is still widely used in the social sciences. His theory implies the existence of a critical time factor relative to motivation.

Relationships exist between motivation and learning. 2. The cognitive. Motivational Factors Factors that influence motivation can serve as incentives or obstacles to achieve desired behaviors. Each theory attempts to address the complex and somewhat elusive quality of motivation. Facilitating or blocking factors that shape motivation to learn can be classified into three major categories. Both creating incentives and decreasing obstacles to motivation pose a challenge for the nurse as an educator of patients. between motivation and behavior. which are organized by their level of potency. When a need is fairly well satisfied. What may be a motivational incentive for one learner may be a motivational obstacle to another. 1. and between motivation. the next potent need emerges. needs satisfaction. social and psychomotor domains of the learner can be influenced by the patient educator. Learner relationship systems . Environmental influence  It includes the surroundings and the attitudes of others. safety. and humanistic interpretations of motivation that emphasize personal choice. physiological. whereas others are weakly motivated. Motivational incentives need to be considered in the context of the individual. expectancy theory encompassing value and perceived chance of success. Some individuals are highly motivated. The nurse-patient interaction may also satisfy the next most potent needs. personality in which motivation is acknowledged to be a stable characteristic. love/belonging and self-esteem. developmental and psychological component of the individual learner. Redman (2007) categorizes theories of motivation that direct learning as behavioral reinforces. affective. Personal attributes  It is consists of physical. those of safety. Maslow noted the relatedness of needs. self-esteem and self actualization. who can act as motivational facilitator or blocker. 3. learning and behavior. reduction of discomforting inconsistencies as a result of cognitive dissonance. love and belongingness. Motivation may be viewed in relation to learning in many ways.principles. allocating causal factors known as attribution.

Learner’s views about the complexity or extent of changes that are needed can shape motivation. Environmental Influences The environment can create. Conversely. Such as those of significant other. One’s perception of the difference between current and expected states of health can be motivating factor in health behavior and can drive readiness to learn. will the healthcare personnel be . and once there. Can the client physically access a health facility. promote or detract from learning. interruptions and lack of privacy can interfere with the capacity to concentrate and learn. comfortable and adaptable individualized surroundings can promote a state of readiness to learn. Accessibility and availability of resources include physical and psychological aspects. community and educator-learner interaction. Environmental factors that influence the motivational level of the individual include:    Physical characteristics of the learning environment Accessibility and availability of human and material resources Different types of behavioral rewards Pleasant. noise. Personal Attributes Factors that can shape an individual’s motivation to learn include personal attributes such as:           Developmental stage Age Gender Emotional readiness Values and beliefs Sensory functioning Cognitive ability Educational level Actual or perceived state of health Severity of illness Ability to achieve behavioral outcomes is determined by an individual’s physical. confusion. emotional and cognitive status. family.

The health-promoting use of these systems needs to be taken into account. work. such as feeling of a personal sense of fulfillment. Attitude influences the client’s engagement with the healthcare system. educator-learner interaction. and serve to facilitate or block the desire to learn. emotional support and communication skills. all influence an individual’s motivation. Rewards can be extrinsic. including healthcare seeking and healthcare decision making. Motivational Axioms Axioms are premises on which an understanding of a phenomenon is based. such as praise or acknowledgement and it can be intrinsic. school and community roles. Individuals are viewed in the context of family/community/cultural systems that have lifelong effects on the choices that individuals make. It includes: o State of optimum anxiety o Learner readiness o Realistic goals o Learner satisfaction/success o Uncertainty-reducing or uncertainty-maintaining dialogue . socio-cultural competence. The nurse as patient educator needs to understand what is involved in promoting motivation of the learner. Behavioral reward support learner motivation. It includes factors such as promptness of services. cultural identity. These significant other systems may have even more of an influence on health outcomes than commonly acknowledged. Motivational axioms are rules that set the stage for motivation.psychologically available to the client? Psychological availability refers to the healthcare system and whether it is flexible and sensitive to patient’s needs. All of these factors are forces that affect motivation. The manner in which the healthcare is perceived by the client affects the client’s willingness to participate in health-promoting behaviors. The learner exists in the context of relationship systems. gratification or self-gratification. Relationship Systems Family or significant others in the support system.

A moderate state of anxiety can be comfortably managed and is known to promote learning. learn and adapt is operative (Peplau 1979). concentrate and learn is reduced. focus attention. An incentive to one individual can be a deterrent to another.State of Optimum Anxiety Learning occurs best when a state of moderate anxiety exists. In this optimum state for learning. which shape the desired behavior toward goal attainment. Learner Satisfaction/Success . however. use of humor or relaxation tapes. Incentives are specific to the individual learner. the patient then will respond with a higher level of information retention. making information relevant and accessible. Unrealistic goals that waste valuable time can set the stage for the learner to give up. Desire cannot be imposed on the learner. the nurse educator offers positive perspectives and encouragement. Mutual goal setting between the learner and the nurse reduces the negative effects of hidden agendas or the sabotaging of educational plans. Learner Readiness The desire to move toward a goal and readiness to learn are factors that influence motivation. external or internal In patient education. at high or severe levels of anxiety. and creating an environment conducive to learning. Above this optimum level. Incentives in the form of reinforce and rewards can be tangible or intangible. Setting realistic goals is a motivating factor. the ability to perceive the environment. nurses can facilitate motivation to learn. By ensuring that learning is stimulating. Learning what the learner wants to change is a critical factor in setting realistic goals. one’s ability to observe. Realistic Goals Goals that are reasonable and possible to achieve are goals toward which an individual will work. It can. The nurse must be able to aid a patient in reducing hi anxiety. be critically influenced by external forces and be promoted by the nurse. through techniques that are applicable or appropriate to the situation such as guided imagery. Goals that are beyond one’s reach are frustrating and counterproductive.

Mishel (1990) views uncertainty as a necessary and natural rhythm of life rather than an adverse experience. When a learner feels good about step-by-step accomplishments. If the decision to use a particular position is not premature. curiosity. stress factors. In a cyclical process. On the other hand. focusing on one’s weak performance can reduce one’s self-esteem. . Individuals carry on “self talk”. It can capitalize on readiness for change and influence health behaviors of the learner. Assessment of Motivation How does the nurse know when the learner is motivated? Redman (2001) views motivational assessment as a part of the general health assessment and states that it includes such areas as level of knowledge. such as those focusing on previous attempts. Focusing on successes as a means of positive reinforcement promotes learner satisfaction and instills a sense of accomplishment. behavior will often follow a dialogue that examines uncertainty. self-care ability. In collecting assessment data the nurse can ask several questions of the learner. thus maintaining uncertainty. Uncertainty in sufficient concentration influences choices and decision making. When one wants to change a state of health. survival issue and life situations. Uncertainty Reduction or Maintainance Uncertainty and even certainty can be a motivating factor in the learning situation.The learner is motivated by success. success and self-esteem escalate moving the learner toward accomplishment of goals. Premature uncertainty reduction can be counterproductive to the learner who has not sufficiently explored alternatives. then uncertainty will promote exploration of alternative positions. Uncertainty influences choices. when the probable outcome of health behaviors is more uncertain. On the other hand. and it can capitalize on receptivity or readiness for change. motivation is enhanced. then behaviors may maintain uncertainty. Some learners may maintain current behaviors given probabilities of treatment outcomes. decision-making capacity of the individual and screening of target populations for educational programs. client skills. Success is self-satisfying and feed one’s self-esteem. goal setting. Individuals have ongoing internal dialogues that can either reduce or maintain uncertainty. they think things through.

In particular. By using communication skills. the presence of cognitions in the form of facilitative beliefs proposed by Wright. Behaviors that can be observed as the learner moves toward preset or planned realistic health or practice goals can serve as objective measurement of motivation. If desired. affective. and based on concepts. To assess motivation. self report measurement could be developed for educational programs. experiential. Measurement of motivation is another aspect to be considered. We can indicate the desire toward an expected health outcome through statements that are made by the clients. Becker’s (1974) notion likelihood of engaging in action. then the learner is likely to be motivated. Subjective self-reports indicate the level of motivation from the learner’s perspectives. Bandura’s (1986) construction of incentive motivators. because teachinglearning is a two way process. Watson and Bell (1996) provides a comprehensive and multidimensional assessment of the level of learner motivation. A subjective means of assessing level of motivation is through dialogue. environmental and learning relationship variables need to be considered. physiological. If the learner’s responses to dimensions are positive.Motivational assessment of the learner needs to be comprehensive. motivation can be assessed through both subjective and objective means. Nonverbal cues can also indicate motivation. Ajzen and Fishbein’s (1980) intent and attitude. These theories guide assessment of the learner motivation. the nurse can obtain verbal information from the client. Additionally. and Barofsky’s (1978) focus on alliance in the learning situation. Pender’s (1996) commitment to a plan of action. several perspectives need to be considered. Comprehensive Parameters for Motivational Assessment of the Learner • Cognitive Variables o Capacity to learn o Readiness to learn  Expressed self-determination  Constructive attitude  Expressed desire and curiosity  Willingness to contract for behavioral outcomes o Facilitating beliefs Affective Variables o Expressions of constructive emotional state o Moderate level of anxiety • . systematic. Cognitive. Assessment of the learner motivation involves the nurse’s judgment.

As a motivational technique.• • • • Physiological Variables o Capacity to perform required behavior Experiential Variables o Previous successful experiences Environmental Variables o Appropriateness of physical environment o Social support systems  Family  Group  Work  Community resources Educator-Learner Relationship System o Prediction of positive relationship Motivational Strategies As nurses. that intrinsic motivations. Concept mapping as a less instructor-regulated learning activity promotes interest and value. The critical question for the nurse to ask is. concept mapping facilitates the acquisition of complex new knowledge through visual links that acknowledge previous learning. Motivational strategies for patient learning are extrinsically generated through the use of specific incentives. however. which enables the learner to integrate previous learning with newly acquired knowledge through diagrammatic “mapping”. however. under what circumstances. He noted. Learner interest is sustained by perceived competence and autonomy. is desired by this learner?” Cognitive evaluation theory (Ryan & Deci 2000) posits that knowing how to foster motivation becomes essential since educators cannot rely on intrinsic motivation to promote learning. we need to find the spark that motivates the learner and that is quite challenging to the educator. that autonomy and competence are intrinsic motivators that can be fostered by selected teaching strategies. Rarely does motivation occur without extrinsic influence. They note. although highly appealing is elusive. One contemporary nursing educational strategy that can be used to promote motivation is concept mapping. . Incentives and motivation are both stimuli to act. How does one motivate a seemingly unmotivated person? As we have discussed earlier that incentives to motivation can be either intrinsically or extrinsically generated. but we cannot motivate them”. in what time frame. Bandura (1986) associates motivation with incentives. Green and Kreuter (1999) note that “strictly speaking we can appeal to people’s motive. “What specific behavior.

clearly communication directions and expectations is critical. and the extent to which self-evaluation is positive. the Attention. expectations. known as achievement motivation (Atkinson. level of difficulty. Reducing or eliminating barriers to achieve goals is also an important way to enhance motivation. in what time frame. needs and personal choices. When teaching others. 1989). the use of rewards. 19864). then the individual is likely to move away from the desired outcome. . uses case studies and varies the way materials are presented. “What specific behavior. giving positive verbal feedback. focuses on creating and maintaining motivational strategies used for teaching. praise. An appeal can be made to the innate need for the learner to succeed. Relevance.Motivational strategies for the nurse as educator are extrinsically generated through the use of specific incentives. and providing opportunities for success are some examples of motivational strategies (Haggard. When considering strategies to improve learner motivation. This model emphasized strategies that the teacher can use to effect changes in the learner by creating a motivating learning environment. is desired by this learner?” Strategizing begins with a systematic assessment of the learner motivation. under what circumstances. Maslow’s (1943) hierarchy of needs should also be taken into consideration.  Satisfaction o It pertains to the ability to use a new skill. usefulness. learner attributes and sense of accomplishment. The critical question for the nurse to ask is.  Relevance o It refers to focusing on the learner’s experiences. Confidence. Organizing material in a way that makes information meaningful to the learner.  Attention o It introduces opposing positions. and Satisfaction (ARCS) Model.  Confidence o Confidence of the learner is influenced by learning requirements. One particular model developed by Keller (1987). When applicable incentives are absent or reduced.

personal vulnerability. This method has been use as a strategy to explore client motivation for adherence to health regimens. Health Behaviors of the Learner Motivation and compliance are concepts relevant to health behaviors of the learner. This could be a useful tool for the nurse as educator in motivational strategizing. Zimmerman et al (2000) developed a readiness to change ruler for motivational interviewing in which the client self-reports preparedness to change. efficacy of proposed change and the ability to effect the change are important in patient education efforts. explain or predict health behaviors will increase the range of health-promoting strategies for patient education. Challenging constraining beliefs and promoting facilitating beliefs are. It is an individualized. it would also be beneficial to consider Damrosch’s (1991) proposal that client health beliefs. empathetic and goal directed. The interviewer seeks to gain knowledge about health beliefs. Health behavior frameworks are blueprints that can be used to maintain desired patient behaviors or promote changes. It takes into consideration problem solving. 1974). The principles inherent in each can be used either to facilitate motivation or to promote compliance to a health regimen. a familiarity with models and theories that describe. As a consequence. flexible. Beliefs are a major construct proposed by Wright et al (1996) as the heart of healing in families. Motivational interviewing is a method of staging readiness to change for the purpose of promoting desired health behaviors. Health Belief Model The original Health Belief Model was developed in the 1950s to examine why people did not participate in health-screening programs (Rosentock. offered as motivational strategies. An understanding of the individual’s mental representations or beliefs is also foundational to the common sense model in the representational approach to patient education (Levanthal & Diefenbach. 1991). therefore. The nurse focuses on health education as well as the expected health behaviors. confidence in change and resistance to chance.In motivational strategizing. patient-cantered approach that is supportive. whereas constraining beliefs can restrict options. This model was modified by . Facilitating beliefs can promote a desire change.

and (2) the belief that health is highly valued. 1977). All of the components are directed toward the likelihood of taking recommended preventive health action as the final phase of the model. in conjunction with cues to action (mass media. The individual perceptions component comprises perceived susceptibility or perceived severity of a specific disease. The likelihood of action component consists of the subcomponents of perceived benefits of preventive action minus perceived barriers to preventive action. The model has been widely used to study patient behaviors in relation to preventive behaviors and acute and chronic illnesses. influence the subcomponent of perceived threat of the specific disease.Becker (1974) to address compliance to therapeutic regimens. race. It is also used to predict preventive health behavior and to explain sick-role behavior. advice. and structural variables (knowledge about and prior contact with disease). individual perceptions and modifying factors interact. These variables. Becker (1990) notes two major premises of the model that need to be present: (1) the client’s willingness to participate in disease prevention and curing regimens. peer and reference group pressure). sex. An individual appraisal of the preventive action occurs. studies have supported the validity of this model. Charron-Prachnowik et al (2001) studied reproductive health behavior in adolescents with Type 1 Diabetes and found that preconception counseling is a motivational cue that triggers positive health outcome. Over time. socio-psychological variables (personality. social class. 3. . Jachna and ForbesThompson (2005) studied health belief constructs in an assisted living facility and found healthcare providers can influence health beliefs relative to osteopororis which has implications for gerontological nursing education. The figure shows the direction and flow of three components. which is followed by a prediction of the likelihood of action. The Health Belief Model has been the predominant explanatory as well as differences in preventive use of health services (Langlie. The modifying factors component consists of demographic variables (age. reminders. Both of these premises need to be present for the model to be relevant in explaining health behavior. ethnicity). locus of control. each of which is further divided into subcomponents: 1. reading material). In some. illness. 2.

Dutta-Bergman (2004) suggests a relationship between health beliefs. Janz and Becker (1984) reviewed the Health Belief Model literature over a 10-year period and found that the model was robust in predicting health behaviors. They indicate that health educators need to be concerned with consumer health-seeking behaviors in the technology age.Findings from studies such as these can be operationalized through educational programs specific to high-risk population. . with perceived barriers being the most influential factor. information seeking and active versus passive learners with implications for type of health education delivery. Therefore. such as using printed materials for teaching that the patient can understand. the nurse needs to take into consideration the availability of the barrier-free educational resources.

activity-related affect. which consist of two variables. which consists of health-promoting behavior partially mediated by commitment to a plan of action and influenced by immediate competing demands and preferences. The emphasis on actualizing health potential and increasing the level of well-being is using approach behaviors rather than avoidance of disease behaviors distinguishes this model as a health promotion rather than a disease prevention model. Behavioral outcomes. . Individual characteristics and experiences. perceive barrier to action. Behavior-specific cognitions and affect. developed on 1987 and revised by Pender (1996). has been primarily used in the discipline of nursing. which consist of perceived benefits of action. the prior related behavior and the personal factors 2. The sequence of the three major components and variables are as follows: 1.Health Promotion Model (Revised) The Health Promotion Model. perceived self-efficacy. interpersonal influences and situational influences 3.

Rothman. The Health Promotion Model and the Health Belief Model share several schematic similarities. The results of this qualitative study (N=34) show Pender’s model as a useful methods of encouraging senior citizen participation in health-promoting activities. It is a predictive theory in the sense that it deals with the belief that one is competent and capable of accomplishing a specific behavior. whereas the revised Health Promotion Model targets positive health outcomes. Self-Efficacy Theory Self-Efficacy Theory is based on a person’s expectations relative to a specific course of action developed from social-cogntitive perspectives (Bandura). Ross-Kerr. and the need for lifestyle change. Vicarious experiences such as observing successful expected behavior through the modeling of others 3. In this adapted model. Performance accomplishment evidenced in self-mastery of similarly expected behaviors 2. and immediate competing demands and preferences. The belief of competency and capability relative to certain behaviors is a precursor to expected outcomes.The revised model was expanded to include these three variables: activity-related affect. Mufunda. Hjelm. but the Health Belief Model targets the likelihood of engaging in preventive health behaviors. Brian and Foley (2005) used the model in an underserved community to develop programs such as lead poisoning in children prevention. These programs decreased barriers to healthcare access. Verbal persuasion by other who present realistic beliefs that the individual is capable of the expected behavior . self-efficacy is used as an outcome determinant. and Kemp (2003) call for a curricular change that prepares nurses for new roles in health promotion in order to expand public awareness of pandemic nature of Type 2 diabetes. Cousins and Wilson (2003) addressed community-based health promotion and used the health model to interpret data and explain health behavior of low-income senior citizens in a 10-month community-based health promotion program. Nambozi. commitment to a plan of action. Buijs. Research support for the health promotion model has been shown in a variety of settings. Both models describe the use of factors or components that impact on perceptions. According to Bandura. self-efficacy is cognitively appraised and processed through four principal sources of information: 1. Lourie. tobacco awareness and prenatal education.

. noting that nurses are in a key position to promote self-care and healthy aging. self-instruction. Kaewthummanukul and Brown (2006) reviewed the literature from 11 studies and concluded that self-efficacy was the best predicator in an employee physical activity program and could be used in occupational health nursing. exposure. Indeed. Callaghan (2005) studied relationships between self-care behaviors and selfefficacy in the older adult population (N=235). desensitization. She found a significant relationship between self care behaviors in older women and self-efficacy. Emotional arousal through self-judgment of physiological states of distress Bandura (1986) notes that the most influential source of efficacy information is that of previous performance accomplishment. Efficacy expectations (expectations relative to a specific course of action) are induced through certain modes. Self-efficacy has proved useful in predicting the course of health behavior. Modes of induction include.4. but are not limited to. suggestion and relaxation. nursing literature has addressed linkages between self-efficacy and self-care.

smoking and drinking behaviors. Protection Motivation Theory Protection Motivation Theory (Prentice-Dunn & Rogers. demonstrations and verbal reinforcement parallel modes of selfefficacy induction. Prochaska (1996) notes six distinct stages of change: precontemplation. Li. also known as the transtheoretical model is another model that informs us to the phenomenon of health behaviors of the learner. action. AIDS. protection motivation theory has tested antecedents to health behaviors such as drug abuse. The protection motivation theory goes beyond the likelihood of action in the health belief model and self-efficacy intent to health behavior action.The use of the Self-Efficacy Theory is particularly relevant in developing educational programs. maintenance and termination. contemplation. Wu. 1986) explains behavioral change in terms of threat and coping appraisal. 1. A threat to health is considered a stimulus to protection motivation. Stanton. Galbraith and Cole (2005) found that adolescent drug trafficking can be predicted by an overall level of health protection motivation. This linear theory includes sources of information (environmental and intrapersonal) that are cognitively processed by appraisal of threat and coping to form protective motivation. It was originated from the field of psychology and was developed around addictive and problem behaviors. The behavior-specific predictions of the theory can be used for understanding the likelihood of individuals to participate in existing or projected educational programs. They suggested that the theory be considered in the design of drug trafficking prevention programs. Influenced by crisis and self-efficacy theories. Precontemplation . Stages of Change Model The Stages of Change Model. Educational strategies such as modeling. which leads to intent and ultimately to action. Evidenced-based research can uncover motivational information that can be used to inform health educators in the design of the educational programs that specifically target highrisk individuals or groups for selected risk behaviors. preparation.

countering (substitute behaviors). This is the busiest stage and strategies include commitment to the change. Individuals have no current intention of changing. More recent use of model in nursing research has focused on its value in health promotion and the processes by which people decide to change (or not to change) behaviors. Strategies involve simple observations. Strategies include a firm and detailed plan of action. Strategies involved increased consciousness raising. Kely (2005) . only that maintenance becomes less vigilant. Preparation a. Paul and Sneed (2004) examined readiness for behavior change in patients with heart failure and noted that it is “not realistic to expect patients to make changes that they are not prepared to make”. Recently. self-reward. Individuals are planning to take action within the time frame of 1 month. However. 6. as well as strategies that will enable completion of each stage (Saarman et al 2000). Maintenance a. 4. Individuals accept or realize that they have a problem and begin to think seriously about changing it. 3. 2. including overconfidence. and relapse self-blame. It occurs when the problem no longer presents any temptation. There are common challenges to this stage. some experts note that termination does not occur. Action a. Termination a. daily temptation. The stages of change model have been used to investigate health behaviors such as smoking cessation and dietary habits. It is useful in nursing to stage the client’s intentions and behaviors for change. 5. The strategies in this stage are the same for the action stage. which has implications for a variety of educational settings. Maintenance is a difficult stage to achieve and may last 6 months to a lifetime. Contemplation a. This popular model can be used with children and adults. There is overt/visible modification of behavior.a. creating a friendly environment and supportive relationships. confrontation or consciousness raising. Motivation and readiness to change are seen as important constructs.

It is based on the premise that humans are rational decision makers who make use of whatever information is available to them. In a two-pronged linear approach. Attitudes toward persons are not an integral part of this theory. specific behavior is determined by (1) belieds. subjective norms and intention. tested the Theory of Reasoned Action to determine nurse practitioner attitudes toward teaching testicular self-examination. attitude toward the behavior and intention and (2) motivation to comply with influential persons known as referents.developed the commitment to health scale that shows potential as a research instrument for measuring the final stage of change. rather the focus is on the predicted behavior. The results showed that nurse practitioners were engaged in this teaching behavior and suggest the . in a large scale (N=1490) study. Kleier (2004). Theory of Reasoned Action The Theory of Reasoned Action emerged from a research program that began in 1950s and is concerned with prediction and understanding of any for of human behaviors with social context (Ajzen & Fishbein 1980). The person’s intention to perform can be measured by relative weights of attitude and subjective norms. This stage could be viewed as an educational outcome in terms of health behaviors of the learner.

The Therapeutic Alliance Model uses and compares the components of compliance.importance of including strategies to promote positive values as components of nurse (educational) preparation. Therapeutic Alliance Model Barofsky’s (1978) Therapeutic Alliance Model addresses a shift in power from the provider to a learning partnership in which collaboration and negotiation with the patient are key. This interpersonal partnership model is appropriate in the educational process when shifting the focus from the patient as a passive-dependent learner to one of an active learner. Hanson (2005) investigated ethnic differences in cigarette smoking intention among female teenagers and found attitude to be the greatest predictor of intention to smoke in Hispanic as well as non-Hispanic White teenagers. the role of the patient is neither passive nor rebellious. The nurse-patient relationship must change from coercion in compliance and from conforming in adherence to collaboration in alliance. Nurses as educators need to take beliefs. with an outcome expectation of self-care. but rather active and responsible. The power in the relationship between the participants is equalized by alliance. adherence. The nurse as teacher and the patient as learner form a collaborative alliance with the goal of self care. and alliance. particularly for educators who want to understand the attitudinal context within which behaviors are likely to change. The expected outcomes are not compliant dependence or counter-dependence. Self determination and control over one’s own life if fundamental to this model. Kemp and Tingen (2000) suggest the use of the theory as s framework for conducting empirical studies for smoking prevention in preteens. . The patient is viewed as active and responsible. It serves as a guide to refocus education efforts on collaboration rather than on compliance. According to Barofsky (1978). A therapeutic alliance is formed between the caregiver and receiver in which both participants are viewed as having equal power. which has implications for educational program development. change is needed in the way nurse and patient interacts. McGahee. but responsible self care. In alliance. attitudinal factors and subjective norms into consideration when designing educational programs relating to intent to change a specific health behavior. The Theory of Reasoned Action is useful in predicting health behaviors.

notes that these terms have a negative connotation and a shift in the balance of power towards the patient lies in the consultative process known as concordance. she notes there is a shit in the balance of power from the professional to the patient. Motivational interviewing also interfaces with the therapeutic alliance model. which is consultation that allow mutual respect for the patient’s and professional’s beliefs. Duran (2003) notes that successful motivational interviewing takes place in an atmosphere of the client being understood and respected and is collaborative in nature with the highest priority placed on the client’s autonomy and freedom of choice. in a recent exploration concepts of compliance and adherence. Luker and Caress (1989) support the notion of therapeutic alliance in patient education. or they may be seen as so dissimilar that one would be inappropriate for a . arguing that “nurses have resisted equalizing their role with patients”. Similarities and Dissimilarities Models may be seen as so similar that there would be a negligible difference in choosing one over the other. They encourage the transfer of responsibility for learning from nurse to patient. the focus is on the process. Although concordance should lead to improved health outcomes. and allows negotiation to take place about the best course of action for the patient.Hobden (2006). Models for Health Education Selection of models for educational use can be made with respect to (1) similarities and dissimilarities (2) nurse as educator agreement with model conceptualizations and (3) functional utility.

A cursory comparative analysis of the different frameworks reveals that the health belief model and the health promotion model are similar. The theories lend themselves more easily to less complex model testing than either the health belief model or the health promotion model because the former are more linear in conceptualization. Each uses comparable salient factors of individual perceptions and competing variables. self-efficacy theory. followed by intent or commitment to action and the health behavior. One major difference between the health belief model and the protection motivation theory is that the later has a component of fear appraisal and focuses on a specific vulnerability rather than general susceptibility to illness (Prentice-Dunn & Rogers. These frameworks also recognize the multidimensional nature. health promotion model. Protection motivation theory is similar to the health promotion model and the theory of reasoned action in the sense that information of cognitively processed. The differences relate to the patient focus. Specificity of behaviors may aid in targeting outcomes of educational programs. the protection motivation theory and the theory of reasoned action in that change is time relevant with implications for educational interventions. The stages of change model appears to be less complicated and does not take into account personal characteristics or experiences. The health belief model emphasizes susceptibility to disease and the likelihood of preventive action. The self-efficacy theory and the theory of reasoned action are similar in that they focus on the predictions or expectations of specific behaviors. The health belief model.specific educational purpose. whereas the health promotion model emphasizes health potential and health-promoting behaviors. All of the models acknowledge the importance of the patient in decision making with the respect to health behaviors. specificity of behavior and outcomes. The differences appear in the models’ basic premises and outcomes. or beliefs relative to the individual and factors external to the individual that can modify health behaviors. 1986). The stages of change model is similar to the selfefficacy theory and the theory of reasoned action in the sense that these models focus on the intent. protection motivation theory and theory of reasoned action are similar in that they acknowledge factors such as experiences. perceptions. . complexity and probability of health behaviors. It differs from the self-efficacy theory. the relative importance of modifying factors.

When applied to the educational arena. which may or may not agree with some of the tenets of each of the models presented. when frustrated.The most dissimilar model is the therapeutic alliance model. the model or models that fit best with the educator’s own beliefs are more likely to be chosen. But this behavior may be altogether rational from the patient’s perspectives”. Staging the individual’s readiness for change and developing strategies for interventions are helpful in designing educational programs with the stages of change model. “are unable to understand the apparently irrational and selfdestructive action of their patients and sometimes throw their hands up in despair. its simplicity and parsimony are strengths. can be bases on the educator’s level of agreement with salient factors in each framework. Functional Utility of Models Model selection for educational purposes can also be based on functional utility. Though in-depth analysis of each model. Understanding of the client as learner can be uncovered in the therapeutic alliance model. therefore. Educator Agreement with Model Conceptualizations Nurses as educators have beliefs systems. Addressing potentially frustrating patient education situations such as noncompliance. Likelihood of action is best addressed by the health belief model. The choice of a model. the educator-learner relationship is the critical factor. Ultimately. Questions to be asked to determine functional utility are as follows:  Who is the target learner?  What is the focus of the learning?  When is the optimal time? . bedeviled by the seeming irrationality of the patient’s behavior. the attention of the educator may be drawn to other factors as well. Although it is relatively narrow in scope. while attaining positive health outcomes is the focus of the health promotion model and the protection motivation theory. Hochbaum (1980) noted that patient educators. Attitude and intention are best viewed through the theory of reasoned action. Belief in one’s capabilities is best addressed by self-efficacy theory and the therapeutic alliance model is best used for reduction of noncompliance through an educator-learner collaboration.

such as those considered at high risk and those diagnosed with acute or chronic illnesses. Integration of Models for Use in Education Theories provide blueprints for interventions. Except for the stages of change model. expectations of specific health practices or focus on self-care. Where is the process to be carried out? The question of who the learner is deals with whether the target learner is the individual. It is apparent that determining optimal time can be a motivational incentive in terms of meeting the health needs of the learner. school. Another consideration in terms of the target learner is categorical groups. self-efficacy theory. specific disease. The important notion for the nurse as educator to remember is the probability of individual variation. From the previous discussion. and prevention of untimely delays in moving toward a desired goal. the timing of the educational experience and the setting in which the learning is to take place. When salient factors are taken into consideration in light of developmental stages of the learner. promotion of wellness. The health belief model. What is needed relates to the focus of the learning and addresses the content to be taught. a mutually convenient time. protection motivation theory. The settings of home. it is clear that the integration of various components of the health behavior models is advantageous in the educational process. . All of the models discussed lend themselves to these diverse settings. institution or specific community locations are all options. an integrated motivational model of learning in health promotion could emerge. Addressing the question of where the educational process is to be carried out is another aspect of functional utility. such as disease processes. health promotion model. timing is an often neglected factor in the models discussed. family or group. The question of when is one of the optimal timing and refers to the readiness of the learner. this critical factor has received little specific reference in terms of health promotion models. The functional use of the models can also be determined by the content needed. stages of change model and theory of reasoned action can be used across the range of these target learners. Although considered important in the context of health education. workplace.

but are not limited to. hierarchy of needs. She found only partial support for the model. andragogy (teaching adults) and gerogogy (teaching older adults) to meet the needs of the learner. in combination with salient health promotion factors. physiological capacity. Gebhardt and Maes (2001) advocate for a multitheory approach to promote health behaviors. Salient health promotion factors that can be used in a multitheory approach to health education include. Developmental stages of the learner incorporate principles of pedagogy (teaching children). A more comprehensive and holistic model for the nurse as educator could emerge when learning is viewed along a unidirectional development continuum. quality of life and voluntary participation in learning. past experiences. knowledge from educational theories and health behavior models allows for an integrated approach to shaping health behaviors of the learner. noting that a synthesized model is appropriate for the study of persons from varying cultural backgrounds. . and it necessarily affects the educator concerned with motivational behaviors of the learner. contractor. perceptions. For example. The roles if the nurses as educators include facilitator of change. values. level of anxiety. suggesting a new model that would incorporate self-efficacy as well as locus of control. educator-learner alliance. Combining content specific to the discipline of nursing. mutual and realistic goal setting. The Role of Nurse as Educator in Health Promotion Nurses as educators are in a position to promote healthy lifestyle. self-confidence. attitudes. The development of new models and/or the revision of older models are necessary steps in the evolution and delivery of healthcare. environment. level of knowledge. intention. skills mastery. Cautioning against the use of unidirectional and nondynamic views of behavioral change. resources and reinforcements.Recent literature proposes model integration. they propose an integrative approach using goal theories and stages of change. sociocultural enablers. Chiu (2005) investigated the previously untested Bruhn an Parcel (1982) model of children’s health promotion in adolescents with Type 1 diabetes using structure equation modeling analysis. beliefs. organizer and evaluator. Poss (2001) developed a new model synthesizing the health belief model and the theory of reasoned action.

The nurse needs to be approachable. what. When education is viewed in the context of the client. The fit between the client as learner and the nurse as educator has the capacity to facilitate learning. indeedm the goodness of fot between these two educational participants can be motivating factor. In 1987. Health education and health promotion are integral to this effort. The plan of action needs to be as possible and include the who. to promote health. trustworthy. learning is individualized. when. The learner trusts that the nurse as educator possesses a respectable. Informal or formal contracts delineate and promote learning objectives. because patients are expected to take increasingly more responsibility and control in the decisions that affect their own health. trust is a key ingredient. Do the client and educator share an understanding of backgrounds or language? Is there a mutual understanding of goal setting? Are health beliefs respected? A contract involves a trusting relationship. of course. Responsibilities that are clearly stated aid in evaluating the plan and directing plan revisions. rather than the client in the context of education.Facilitator of Change The goal of the nurse educator is. current body of theoretically based and clinically applicable knowledge. educational contracting involves stating mutual goals to be accomplished. because the learner’s own health status is often valued as a private matter. In light of our changing healthcare system. At the same time. where and hoe of the learning process. there needs to be an emphasis on patientnurse partnerships. Similar to the nursing process. Educational contracting is the key to informed decision making. In a mutually satisfying teacher-learner relationship system. devising an agreed-upon plan of action. the nurse trusts that when the client . Contractor Contracting has been a popular means of facilitating learning. deTornay and Thompson proposed that explaining. When learning is viewed as an intervention. the nurse as educator is an important facilitator of change. analyzing. evaluating the plan and deriving alternatives. and culturally sensitive. dividing complex skills demonstrating practicing asking questions and providing closure are effective in facilitating change in the learning situation. it needs to be considered in the context of the other nursing interventions that will effect change. In turn.

State of Evidence The evidence is less than adequate for implementing nursing interventions that specifically address the variables of compliance and motivations as related to health behaviors of the learner. Luker and Caress challenged the nurse as educator role. As early as 1989. is a task taken on by the nurse as educator. This accountability is ensured by evaluation in the form of outcomes. . and both feel free to learn and make mistakes. They made a distinction between patient education and patient teaching. the learner will demonstrate behaviors that will be health promoting. families and groups in the evaluative measure of learning.enters into an agreement. like other healthcare projects. The difference between the specialist role and the generalist role in education remains largely unsubstantiated by evidence. organization evaluation and peer evaluation are not new concepts. sequential organization of content from simple to complex. Organization of the learning material decreases the obstacles to learning. and determining priority of subject matter. Newman and Brown (1986) list the following elements as part of the ideal relationship: both parties have trust and respect. Evaluative processes are an integral part of all learning. noting that the former is in advanced practice and that not all nurses are prepared to be patient educators. With the explosion of interest in evidence-based nursing practice further conceptually based research that identifies. In the final analysis. describes. learner evaluation. explains and predicts health behaviors of the learner needs to be conducted. including manipulation of materials and space. need to be accountable to the learner or consumer of the health service. Self-evaluation. application of knowledge that improves the health of individuals. Organizer Organization of the learning situation. Evaluator Educational programs. the teacher assumes the student can learn and is sensitive to individual needs. Attendance at educational programs or individual sessions can be organized around the target learner as well as significant others to facilitate the learning process and promote motivation to learn.

Zinn (2005) argues that there is insufficient data to explain why people take health risks and that more research concerning how an individual’s knowledge is shaped and how it impacts health behaviors is needed. certain populations have been underrepresented in motivational research and that motivation may not be able to be effectively measured. motivation and health behaviors of the learner. motivational factors should be a paramount focus of research in nursing education as well as client education. They challenge researchers and practitioners to carefully examine the role of motivation in influencing health behaviors. This document sets the stage for the nurse as educator to use theoretically based strategies to promote desirable health behaviors of the learner. A clarion call is needed for both qualitative and quantitative conceptually grounded research to be infused into the teaching-learning process. . Forums for evidence-based learning ought to be widely established and should include discussion relative to compliance. In light of the critical nursing workforce shortage and nursing faculty shortage. 2000) has established two major goals: (1) to increase the quality and years of healthy life and (2) to eliminate health disparities among different segments of the population.Healthy People 2010 (US Department of Health and Human Service. in an integrative review of motivational research (conducted using the Cumulative Index of Nursing and Allied Health Literatire database) concluded that no clear definition of motivation exists. Carter and Kulbok (2002).