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 long-
lasting. 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
than health outcomes. They conclude that nurses need to act as advocates and acknowledge the
importance of patient’s self-knowledge and decision making.
The expectation of total compliance in all spheres of behavior and at all times is
unrealistic. At times, noncompliant behavior may be desirable and could be viewed as a
necessary defensive response to stressful situations. The learner may use time-outs as the
intensity of the learning situation is maintained or escalates. This mechanism of temporary
withdrawal from the learning situation may actually prove beneficial. Following withdrawal, the
learner could reengage, feeling renewed and ready to continue with an educational program or
regimen. Viewed in this way, noncompliance is not an obstacle to learning and does not carry a
negative connotation.

Motivation
The word motivation comes from the Latin word “movere” that means to set in motion,
motivation is defined as the psychological force that moves a person toward some kind of action.
It is also described as a willingness of the learner to embrace learning, with readiness as evidence
of motivation. According to Kort (1987), motivation is the result of both internal and external
factors and not the result of the external manipulation alone. Implicit in motivation is movement
in the direction of meeting a need or toward reaching a goal.
Lewin, a field theorist, conceptualized motivation in terms of positive or negative
movement toward goals. Once an individual’s equilibrium is disturbed, forces of approach and
avoidance may come into play. He noted that if avoidance endured in an approach-avoidance
conflict, there would be negative movement away from a goal. His theory implies the existence
of a critical time factor relative to motivation. This time factor, however, is generally not a
serious consideration in motivational models of health behavior or motivational research.
Ideally, the nurse educator’s role is to facilitate the learner’s approach toward a desired
goal and to prevent untimely delays.
Maslow developed a theory of human motivation that is still widely used in the social
sciences. The major premises of Maslow’s motivation theory are integrated wholeness of the
individual and a hierarchy of goals. He noted that not all behavior is motivated and that behavior
theories are synonymous with motivation. Many determinants of behavior other than motives
exist, and many motives can be involved in one behavior. Using the hierarchy of needs
principles, physiological, safety, love and belongingness, self-esteem and self actualization,
Maslow noted the relatedness of needs, which are organized by their level of potency. Some
individuals are highly motivated, whereas others are weakly motivated. When a need is fairly
well satisfied, the next potent need emerges. The nurse-patient interaction may also satisfy the
next most potent needs, those of safety, love/belonging and self-esteem.
Relationships exist between motivation and learning; between motivation and behavior;
and between motivation, learning and behavior. Motivation may be viewed in relation to learning
in many ways. Redman (2007) categorizes theories of motivation that direct learning as
behavioral reinforces, needs satisfaction, reduction of discomforting inconsistencies as a result of
cognitive dissonance, allocating causal factors known as attribution, personality in which
motivation is acknowledged to be a stable characteristic, expectancy theory encompassing value
and perceived chance of success, and humanistic interpretations of motivation that emphasize
personal choice. Each theory attempts to address the complex and somewhat elusive quality of
motivation.

Motivational Factors
Factors that influence motivation can serve as incentives or obstacles to achieve desired
behaviors. Both creating incentives and decreasing obstacles to motivation pose a challenge for
the nurse as an educator of patients. The cognitive, affective, social and psychomotor domains of
the learner can be influenced by the patient educator, who can act as motivational facilitator or
blocker.
Motivational incentives need to be considered in the context of the individual. What may
be a motivational incentive for one learner may be a motivational obstacle to another.
Facilitating or blocking factors that shape motivation to learn can be classified into three
major categories.
1. Personal attributes
 It is consists of physical, developmental and psychological component of the
individual learner.
2. Environmental influence
 It includes the surroundings and the attitudes of others.
3. Learner relationship systems
  Such as those of significant other, family, community and educator-learner
interaction.
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,
emotional and cognitive status. 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.
Learner’s views about the complexity or extent of changes that are needed can shape motivation.

Environmental Influences
The environment can create, promote or detract from learning. 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, comfortable and adaptable individualized surroundings can promote a state of
readiness to learn. Conversely, noise, confusion, interruptions and lack of privacy can interfere
with the capacity to concentrate and learn.
Accessibility and availability of resources include physical and psychological aspects.
Can the client physically access a health facility, and once there, will the healthcare personnel be
psychologically available to the client? Psychological availability refers to the healthcare system
and whether it is flexible and sensitive to patient’s needs. It includes factors such as promptness
of services, socio-cultural competence, emotional support and communication skills. Attitude
influences the client’s engagement with the healthcare system.
The manner in which the healthcare is perceived by the client affects the client’s
willingness to participate in health-promoting behaviors. Behavioral reward support learner
motivation. Rewards can be extrinsic, such as praise or acknowledgement and it can be intrinsic,
such as feeling of a personal sense of fulfillment, gratification or self-gratification.

Relationship Systems
Family or significant others in the support system; cultural identity; work, school and
community roles; educator-learner interaction, all influence an individual’s motivation. The
learner exists in the context of relationship systems. Individuals are viewed in the context of
family/community/cultural systems that have lifelong effects on the choices that individuals
make, including healthcare seeking and healthcare decision making.
These significant other systems may have even more of an influence on health outcomes
than commonly acknowledged. The health-promoting use of these systems needs to be taken into
account. All of these factors are forces that affect motivation, and serve to facilitate or block the
desire to learn.

Motivational Axioms
Axioms are premises on which an understanding of a phenomenon is based. The nurse as
patient educator needs to understand what is involved in promoting motivation of the learner.
Motivational axioms are rules that set the stage for motivation. It includes:
o State of optimum anxiety
o Learner readiness
o Realistic goals
o Learner satisfaction/success
o Uncertainty-reducing or uncertainty-maintaining dialogue
State of Optimum Anxiety
Learning occurs best when a state of moderate anxiety exists. A moderate state of anxiety
can be comfortably managed and is known to promote learning. In this optimum state for
learning, one’s ability to observe, focus attention, learn and adapt is operative (Peplau 1979).
Above this optimum level, at high or severe levels of anxiety, the ability to perceive the
environment, concentrate and learn is reduced. The nurse must be able to aid a patient in
reducing hi anxiety, through techniques that are applicable or appropriate to the situation such as
guided imagery, use of humor or relaxation tapes, the patient then will respond with a higher
level of information retention.

Learner Readiness
The desire to move toward a goal and readiness to learn are factors that influence
motivation. Desire cannot be imposed on the learner. It can, however, be critically influenced by
external forces and be promoted by the nurse. Incentives are specific to the individual learner.
An incentive to one individual can be a deterrent to another. Incentives in the form of reinforce
and rewards can be tangible or intangible, external or internal
In patient education, the nurse educator offers positive perspectives and encouragement,
which shape the desired behavior toward goal attainment. By ensuring that learning is
stimulating, making information relevant and accessible, and creating an environment conducive
to learning, nurses can facilitate motivation to learn.

Realistic Goals
Goals that are reasonable and possible to achieve are goals toward which an individual
will work. Goals that are beyond one’s reach are frustrating and counterproductive. Unrealistic
goals that waste valuable time can set the stage for the learner to give up.
Setting realistic goals is a motivating factor. Learning what the learner wants to change is
a critical factor in setting realistic goals. Mutual goal setting between the learner and the nurse
reduces the negative effects of hidden agendas or the sabotaging of educational plans.

Learner Satisfaction/Success
 The learner is motivated by success. Success is self-satisfying and feed one’s self-esteem.
In a cyclical process, success and self-esteem escalate moving the learner toward
accomplishment of goals. When a learner feels good about step-by-step accomplishments,
motivation is enhanced. Focusing on successes as a means of positive reinforcement promotes
learner satisfaction and instills a sense of accomplishment. On the other hand, focusing on one’s
weak performance can reduce one’s self-esteem.

Uncertainty Reduction or Maintainance

Uncertainty and even certainty can be a motivating factor in the learning situation.
Individuals have ongoing internal dialogues that can either reduce or maintain uncertainty.
Individuals carry on “self talk”; they think things through. When one wants to change a state of
health, behavior will often follow a dialogue that examines uncertainty. On the other hand, when
the probable outcome of health behaviors is more uncertain, then behaviors may maintain
uncertainty. Some learners may maintain current behaviors given probabilities of treatment
outcomes, thus maintaining uncertainty.
Mishel (1990) views uncertainty as a necessary and natural rhythm of life rather than an
adverse experience. Uncertainty influences choices. It can capitalize on readiness for change and
influence health behaviors of the learner. Uncertainty in sufficient concentration influences
choices and decision making, and it can capitalize on receptivity or readiness for change.
Premature uncertainty reduction can be counterproductive to the learner who has not sufficiently
explored alternatives. If the decision to use a particular position is not premature, then
uncertainty will promote exploration of alternative positions.

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, client skills, decision-making capacity of the individual and
screening of target populations for educational programs. In collecting assessment data the nurse
can ask several questions of the learner, such as those focusing on previous attempts, curiosity,
goal setting, self-care ability, stress factors, survival issue and life situations.
 Motivational assessment of the learner needs to be comprehensive, systematic, and based
on concepts. Cognitive, affective, physiological, experiential, environmental and learning
relationship variables need to be considered.
To assess motivation, several perspectives need to be considered. Bandura’s (1986)
construction of incentive motivators; Ajzen and Fishbein’s (1980) intent and attitude; Becker’s
(1974) notion likelihood of engaging in action; Pender’s (1996) commitment to a plan of action;
and Barofsky’s (1978) focus on alliance in the learning situation. Additionally, the presence of
cognitions in the form of facilitative beliefs proposed by Wright, Watson and Bell (1996)
provides a comprehensive and multidimensional assessment of the level of learner motivation.
These theories guide assessment of the learner motivation. If the learner’s responses to
dimensions are positive, then the learner is likely to be motivated.
Assessment of the learner motivation involves the nurse’s judgment, because teaching-
learning is a two way process. In particular, motivation can be assessed through both subjective
and objective means. A subjective means of assessing level of motivation is through dialogue.
By using communication skills, the nurse can obtain verbal information from the client. We can
indicate the desire toward an expected health outcome through statements that are made by the
clients. Nonverbal cues can also indicate motivation.
Measurement of motivation is another aspect to be considered. Subjective self-reports
indicate the level of motivation from the learner’s perspectives. If desired, self report
measurement could be developed for educational programs. 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.
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
• 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, we need to find the spark that motivates the learner and that is quite
challenging to the educator. How does one motivate a seemingly unmotivated person? As we
have discussed earlier that incentives to motivation can be either intrinsically or extrinsically
generated. Incentives and motivation are both stimuli to act. Bandura (1986) associates
motivation with incentives. He noted, however, that intrinsic motivations, although highly
appealing is elusive. Rarely does motivation occur without extrinsic influence. Green and
Kreuter (1999) note that “strictly speaking we can appeal to people’s motive, but we cannot
motivate them”. Motivational strategies for patient learning are extrinsically generated through
the use of specific incentives. The critical question for the nurse to ask is, “What specific
behavior, under what circumstances, in what time frame, 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. They note, however, that autonomy and competence are intrinsic motivators that can be
fostered by selected teaching strategies. One contemporary nursing educational strategy that can
be used to promote motivation is concept mapping, which enables the learner to integrate
previous learning with newly acquired knowledge through diagrammatic “mapping”. As a
motivational technique, concept mapping facilitates the acquisition of complex new knowledge
through visual links that acknowledge previous learning. Learner interest is sustained by
perceived competence and autonomy. Concept mapping as a less instructor-regulated learning
activity promotes interest and value.
 Motivational strategies for the nurse as educator are extrinsically generated through the
use of specific incentives. The critical question for the nurse to ask is, “What specific behavior,
under what circumstances, in what time frame, is desired by this learner?” Strategizing begins
with a systematic assessment of the learner motivation. When applicable incentives are absent or
reduced, then the individual is likely to move away from the desired outcome. When considering
strategies to improve learner motivation, Maslow’s (1943) hierarchy of needs should also be
taken into consideration. An appeal can be made to the innate need for the learner to succeed,
known as achievement motivation (Atkinson, 19864).
When teaching others, clearly communication directions and expectations is critical.
Organizing material in a way that makes information meaningful to the learner, giving positive
verbal feedback, and providing opportunities for success are some examples of motivational
strategies (Haggard, 1989). Reducing or eliminating barriers to achieve goals is also an important
way to enhance motivation.
One particular model developed by Keller (1987), the Attention, Relevance, Confidence,
and Satisfaction (ARCS) Model, focuses on creating and maintaining motivational strategies
used for teaching. This model emphasized strategies that the teacher can use to effect changes in
the learner by creating a motivating learning environment.
 Attention
o It introduces opposing positions, uses case studies and varies the way materials
are presented.
 Relevance
o It refers to focusing on the learner’s experiences, usefulness, needs and personal
choices.
 Confidence
o Confidence of the learner is influenced by learning requirements, level of
difficulty, expectations, learner attributes and sense of accomplishment.
 Satisfaction
o It pertains to the ability to use a new skill, the use of rewards, praise, and the
extent to which self-evaluation is positive.
 In motivational strategizing, it would also be beneficial to consider Damrosch’s (1991)
proposal that client health beliefs, personal vulnerability, efficacy of proposed change and the
ability to effect the change are important in patient education efforts.
Beliefs are a major construct proposed by Wright et al (1996) as the heart of healing in
families. Facilitating beliefs can promote a desire change, whereas constraining beliefs can
restrict options. Challenging constraining beliefs and promoting facilitating beliefs are, therefore,
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).
Motivational interviewing is a method of staging readiness to change for the purpose of
promoting desired health behaviors. It is an individualized, flexible, patient-cantered approach
that is supportive, empathetic and goal directed. It takes into consideration problem solving,
confidence in change and resistance to chance. The interviewer seeks to gain knowledge about
health beliefs. This method has been use as a strategy to explore client motivation for adherence
to health regimens. Zimmerman et al (2000) developed a readiness to change ruler for
motivational interviewing in which the client self-reports preparedness to change. This could be
a useful tool for the nurse as educator in motivational strategizing.

Health Behaviors of the Learner

Motivation and compliance are concepts relevant to health behaviors of the learner. The
nurse focuses on health education as well as the expected health behaviors. Health behavior
frameworks are blueprints that can be used to maintain desired patient behaviors or promote
changes. As a consequence, a familiarity with models and theories that describe, explain or
predict health behaviors will increase the range of health-promoting strategies for patient
education. The principles inherent in each can be used either to facilitate motivation or to
promote compliance to a health regimen.

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, 1974). This model was modified by
Becker (1974) to address compliance to therapeutic regimens. 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, and (2) the belief that health is highly valued. Both of these
premises need to be present for the model to be relevant in explaining health behavior.
The figure shows the direction and flow of three components, each of which is further
divided into subcomponents:
1. The individual perceptions component comprises perceived susceptibility or perceived
severity of a specific disease.
2. The modifying factors component consists of demographic variables (age, sex, race,
ethnicity), socio-psychological variables (personality, locus of control, social class, peer and
reference group pressure), and structural variables (knowledge about and prior contact with
disease). These variables, in conjunction with cues to action (mass media, advice, reminders,
illness, reading material), influence the subcomponent of perceived threat of the specific
disease.
3. The likelihood of action component consists of the subcomponents of perceived benefits of
preventive action minus perceived barriers to preventive action.
All of the components are directed toward the likelihood of taking recommended
preventive health action as the final phase of the model. In some, individual perceptions and
modifying factors interact. An individual appraisal of the preventive action occurs, 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, 1977). The model has been widely used to study
patient behaviors in relation to preventive behaviors and acute and chronic illnesses. It is also
used to predict preventive health behavior and to explain sick-role behavior.
Over time, studies have supported the validity of this model. Jachna and Forbes-
Thompson (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. 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.
 Findings from studies such as these can be operationalized through educational programs
specific to high-risk population. 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, with perceived barriers being the most influential factor. Therefore, the nurse needs to
take into consideration the availability of the barrier-free educational resources, such as using
printed materials for teaching that the patient can understand.
Dutta-Bergman (2004) suggests a relationship between health beliefs, information
seeking and active versus passive learners with implications for type of health education
delivery. They indicate that health educators need to be concerned with consumer health-seeking
behaviors in the technology age.
Health Promotion Model (Revised)
The Health Promotion Model, developed on 1987 and revised by Pender (1996), has been
primarily used in the discipline of nursing. 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.

The sequence of the three major components and variables are as follows:
1. Individual characteristics and experiences, which consist of two variables, the prior
related behavior and the personal factors
2. Behavior-specific cognitions and affect, which consist of perceived benefits of action,
perceive barrier to action, perceived self-efficacy, activity-related affect, interpersonal
influences and situational influences
3. Behavioral outcomes, which consists of health-promoting behavior partially mediated by
commitment to a plan of action and influenced by immediate competing demands and
preferences.
 The revised model was expanded to include these three variables: activity-related affect,
commitment to a plan of action, and immediate competing demands and preferences.
The Health Promotion Model and the Health Belief Model share several schematic
similarities. Both models describe the use of factors or components that impact on perceptions,
but the Health Belief Model targets the likelihood of engaging in preventive health behaviors,
whereas the revised Health Promotion Model targets positive health outcomes.
Research support for the health promotion model has been shown in a variety of settings.
Buijs, Ross-Kerr, 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. 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. Rothman, Lourie, Brian and Foley (2005) used the model in an
underserved community to develop programs such as lead poisoning in children prevention,
tobacco awareness and prenatal education. These programs decreased barriers to healthcare
access. Hjelm, Mufunda, Nambozi, 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, and the need for lifestyle change.

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). 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. The belief of competency and capability relative to certain behaviors is a precursor to
expected outcomes. In this adapted model, self-efficacy is used as an outcome determinant.
According to Bandura, self-efficacy is cognitively appraised and processed through four
principal sources of information:
1. Performance accomplishment evidenced in self-mastery of similarly expected behaviors
2. Vicarious experiences such as observing successful expected behavior through the
modeling of others
3. Verbal persuasion by other who present realistic beliefs that the individual is capable of the
expected behavior
 4. 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. Modes of induction include, but are not
limited to, desensitization, self-instruction, exposure, suggestion and relaxation.

Self-efficacy has proved useful in predicting the course of health behavior. Indeed,
nursing literature has addressed linkages between self-efficacy and self-care. 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. Callaghan (2005) studied relationships between self-care behaviors and self-
efficacy in the older adult population (N=235). She found a significant relationship between self
care behaviors in older women and self-efficacy, noting that nurses are in a key position to
promote self-care and healthy aging.
 The use of the Self-Efficacy Theory is particularly relevant in developing educational
programs. The behavior-specific predictions of the theory can be used for understanding the
likelihood of individuals to participate in existing or projected educational programs. Educational
strategies such as modeling, demonstrations and verbal reinforcement parallel modes of self-
efficacy induction.

Protection Motivation Theory

Protection Motivation Theory (Prentice-Dunn & Rogers, 1986) explains behavioral
change in terms of threat and coping appraisal. A threat to health is considered a stimulus to
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, which leads to intent and ultimately to action.
Influenced by crisis and self-efficacy theories, protection motivation theory has tested
antecedents to health behaviors such as drug abuse, AIDS, smoking and drinking behaviors. Wu,
Stanton, Li, Galbraith and Cole (2005) found that adolescent drug trafficking can be predicted by
an overall level of health protection motivation. They suggested that the theory be considered in
the design of drug trafficking prevention programs.
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 high-
risk individuals or groups for selected risk behaviors. The protection motivation theory goes
beyond the likelihood of action in the health belief model and self-efficacy intent to health
behavior action.

Stages of Change Model

The Stages of Change Model, also known as the transtheoretical model is another model
that informs us to the phenomenon of health behaviors of the learner. It was originated from the
field of psychology and was developed around addictive and problem behaviors. Prochaska
(1996) notes six distinct stages of change: precontemplation, contemplation, preparation, action,
maintenance and termination.
1. Precontemplation
 a. Individuals have no current intention of changing. Strategies involve simple
observations, confrontation or consciousness raising.
2. Contemplation
a. Individuals accept or realize that they have a problem and begin to think seriously
about changing it. Strategies involved increased consciousness raising.
3. Preparation
a. Individuals are planning to take action within the time frame of 1 month.
Strategies include a firm and detailed plan of action.
4. Action
a. There is overt/visible modification of behavior. This is the busiest stage and
strategies include commitment to the change, self-reward, countering (substitute
behaviors), creating a friendly environment and supportive relationships.
5. Maintenance
a. Maintenance is a difficult stage to achieve and may last 6 months to a lifetime.
There are common challenges to this stage, including overconfidence, daily
temptation, and relapse self-blame. The strategies in this stage are the same for
the action stage.
6. Termination
a. It occurs when the problem no longer presents any temptation. However, some
experts note that termination does not occur, only that maintenance becomes less
vigilant.
Motivation and readiness to change are seen as important constructs. It is useful in
nursing to stage the client’s intentions and behaviors for change, as well as strategies that will
enable completion of each stage (Saarman et al 2000). 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.
The stages of change model have been used to investigate health behaviors such as
smoking cessation and dietary habits. 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”. This popular model can be used with children and
adults, which has implications for a variety of educational settings. Recently, Kely (2005)
developed the commitment to health scale that shows potential as a research instrument for
measuring the final stage of change. This stage could be viewed as an educational outcome in
terms of health behaviors of the learner.

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). It is based on the premise that humans are rational decision
makers who make use of whatever information is available to them. Attitudes toward persons are
not an integral part of this theory; rather the focus is on the predicted behavior.
In a two-pronged linear approach, specific behavior is determined by (1) belieds, attitude
toward the behavior and intention and (2) motivation to comply with influential persons known
as referents, subjective norms and intention. The person’s intention to perform can be measured
by relative weights of attitude and subjective norms.

Kleier (2004), in a large scale (N=1490) study, tested the Theory of Reasoned Action to
determine nurse practitioner attitudes toward teaching testicular self-examination. The results
showed that nurse practitioners were engaged in this teaching behavior and suggest the
importance of including strategies to promote positive values as components of nurse
(educational) preparation. McGahee, Kemp and Tingen (2000) suggest the use of the theory as s
framework for conducting empirical studies for smoking prevention in preteens, which has
implications for educational program development. 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 Theory of Reasoned Action is useful in predicting health behaviors, particularly for
educators who want to understand the attitudinal context within which behaviors are likely to
change. Nurses as educators need to take beliefs, attitudinal factors and subjective norms into
consideration when designing educational programs relating to intent to change a specific health
behavior.

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.
A therapeutic alliance is formed between the caregiver and receiver in which both participants
are viewed as having equal power. The patient is viewed as active and responsible, with an
outcome expectation of self-care. Self determination and control over one’s own life if
fundamental to this model.
The Therapeutic Alliance Model uses and compares the components of compliance,
adherence, and alliance. According to Barofsky (1978), change is needed in the way nurse and
patient interacts. The nurse-patient relationship must change from coercion in compliance and
from conforming in adherence to collaboration in alliance. The power in the relationship between
the participants is equalized by alliance. In alliance, the role of the patient is neither passive nor
rebellious, but rather active and responsible. The expected outcomes are not compliant
dependence or counter-dependence, but responsible self care.
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. It
serves as a guide to refocus education efforts on collaboration rather than on compliance. The
nurse as teacher and the patient as learner form a collaborative alliance with the goal of self care.
 Hobden (2006), in a recent exploration concepts of compliance and adherence, 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, which is consultation that allow mutual
respect for the patient’s and professional’s beliefs, and allows negotiation to take place about the
best course of action for the patient, she notes there is a shit in the balance of power from the
professional to the patient. Although concordance should lead to improved health outcomes, the
focus is on the process.

Motivational interviewing also interfaces with the therapeutic alliance model. 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.
Luker and Caress (1989) support the notion of therapeutic alliance in patient education,
arguing that “nurses have resisted equalizing their role with patients”. They encourage the
transfer of responsibility for learning from nurse to patient.

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.

Similarities and Dissimilarities

Models may be seen as so similar that there would be a negligible difference in choosing
one over the other, or they may be seen as so dissimilar that one would be inappropriate for a
specific educational purpose. A cursory comparative analysis of the different frameworks reveals
that the health belief model and the health promotion model are similar. Each uses comparable
salient factors of individual perceptions and competing variables. The differences appear in the
models’ basic premises and outcomes. The health belief model emphasizes susceptibility to
disease and the likelihood of preventive action, whereas the health promotion model emphasizes
health potential and health-promoting behaviors.
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 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. Specificity of behaviors may aid
in targeting outcomes of educational programs. The stages of change model is similar to the self-
efficacy theory and the theory of reasoned action in the sense that these models focus on the
intent. The stages of change model appears to be less complicated and does not take into account
personal characteristics or experiences. It differs from the self-efficacy theory, the protection
motivation theory and the theory of reasoned action in that change is time relevant with
implications for educational interventions.
Protection motivation theory is similar to the health promotion model and the theory of
reasoned action in the sense that information of cognitively processed, followed by intent or
commitment to action and the health behavior.
The health belief model, health promotion model, self-efficacy theory, protection
motivation theory and theory of reasoned action are similar in that they acknowledge factors
such as experiences, perceptions, or beliefs relative to the individual and factors external to the
individual that can modify health behaviors. These frameworks also recognize the
multidimensional nature, complexity and probability of health behaviors. 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, 1986).
All of the models acknowledge the importance of the patient in decision making with the
respect to health behaviors. The differences relate to the patient focus, the relative importance of
modifying factors, specificity of behavior and outcomes.
 The most dissimilar model is the therapeutic alliance model. Although it is relatively
narrow in scope, its simplicity and parsimony are strengths. When applied to the educational
arena, the educator-learner relationship is the critical factor. Addressing potentially frustrating
patient education situations such as noncompliance, Hochbaum (1980) noted that patient
educators, when frustrated, “are unable to understand the apparently irrational and self-
destructive action of their patients and sometimes throw their hands up in despair, bedeviled by
the seeming irrationality of the patient’s behavior. But this behavior may be altogether rational
from the patient’s perspectives”. Understanding of the client as learner can be uncovered in the
therapeutic alliance model.

Educator Agreement with Model Conceptualizations

Nurses as educators have beliefs systems, which may or may not agree with some of the
tenets of each of the models presented. The choice of a model, therefore, can be bases on the
educator’s level of agreement with salient factors in each framework.
Likelihood of action is best addressed by the health belief model, while attaining positive
health outcomes is the focus of the health promotion model and the protection motivation theory.
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. Staging the
individual’s readiness for change and developing strategies for interventions are helpful in
designing educational programs with the stages of change model.
Though in-depth analysis of each model, the attention of the educator may be drawn to
other factors as well. Ultimately, the model or models that fit best with the educator’s own
beliefs are more likely to be chosen.

Functional Utility of Models

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

Integration of Models for Use in Education

Theories provide blueprints for interventions. From the previous discussion, it is clear
that the integration of various components of the health behavior models is advantageous in the
educational process. When salient factors are taken into consideration in light of developmental
stages of the learner, an integrated motivational model of learning in health promotion could
emerge.
 Recent literature proposes model integration. For example, Gebhardt and Maes (2001)
advocate for a multitheory approach to promote health behaviors. Cautioning against the use of
unidirectional and nondynamic views of behavioral change, they propose an integrative approach
using goal theories and stages of change. Poss (2001) developed a new model synthesizing the
health belief model and the theory of reasoned action, noting that a synthesized model is
appropriate for the study of persons from varying cultural backgrounds. 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. She found only
partial support for the model, suggesting a new model that would incorporate self-efficacy as
well as locus of control.
The development of new models and/or the revision of older models are necessary steps
in the evolution and delivery of healthcare, and it necessarily affects the educator concerned with
motivational behaviors of the learner.
Salient health promotion factors that can be used in a multitheory approach to health
education include, but are not limited to, level of knowledge, attitudes, values, beliefs,
perceptions, level of anxiety, self-confidence, skills mastery, past experiences, intention,
physiological capacity, sociocultural enablers, environment, educator-learner alliance, resources
and reinforcements, mutual and realistic goal setting, hierarchy of needs, quality of life and
voluntary participation in learning.
Developmental stages of the learner incorporate principles of pedagogy (teaching
children), andragogy (teaching adults) and gerogogy (teaching older adults) to meet the needs of
the learner. A more comprehensive and holistic model for the nurse as educator could emerge
when learning is viewed along a unidirectional development continuum, in combination with
salient health promotion factors.

The Role of Nurse as Educator in Health Promotion

Nurses as educators are in a position to promote healthy lifestyle. Combining content
specific to the discipline of nursing, knowledge from educational theories and health behavior
models allows for an integrated approach to shaping health behaviors of the learner. The roles if
the nurses as educators include facilitator of change, contractor, organizer and evaluator.
Facilitator of Change
The goal of the nurse educator is, of course, to promote health. Health education and
health promotion are integral to this effort. At the same time, the nurse as educator is an
important facilitator of change. When learning is viewed as an intervention, it needs to be
considered in the context of the other nursing interventions that will effect change. In 1987,
deTornay and Thompson proposed that explaining, analyzing, dividing complex skills
demonstrating practicing asking questions and providing closure are effective in facilitating
change in the learning situation.

Contractor
Contracting has been a popular means of facilitating learning. Informal or formal
contracts delineate and promote learning objectives. Similar to the nursing process, educational
contracting involves stating mutual goals to be accomplished, devising an agreed-upon plan of
action, evaluating the plan and deriving alternatives. The plan of action needs to be as possible
and include the who, what, when, where and hoe of the learning process. Responsibilities that are
clearly stated aid in evaluating the plan and directing plan revisions.
In light of our changing healthcare system, there needs to be an emphasis on patient-
nurse partnerships, because patients are expected to take increasingly more responsibility and
control in the decisions that affect their own health. Educational contracting is the key to
informed decision making.
When education is viewed in the context of the client, rather than the client in the context
of education, learning is individualized. 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. 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. In a mutually satisfying teacher-learner
relationship system, trust is a key ingredient. The learner trusts that the nurse as educator
possesses a respectable, current body of theoretically based and clinically applicable knowledge.
The nurse needs to be approachable, trustworthy, and culturally sensitive, because the learner’s
own health status is often valued as a private matter. In turn, the nurse trusts that when the client
enters into an agreement, the learner will demonstrate behaviors that will be health promoting.
Newman and Brown (1986) list the following elements as part of the ideal relationship: both
parties have trust and respect; the teacher assumes the student can learn and is sensitive to
individual needs; and both feel free to learn and make mistakes.

Organizer
Organization of the learning situation, including manipulation of materials and space,
sequential organization of content from simple to complex, and determining priority of subject
matter, is a task taken on by the nurse as educator. Organization of the learning material
decreases the obstacles to learning. 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.

Evaluator
Educational programs, like other healthcare projects, need to be accountable to the
learner or consumer of the health service. This accountability is ensured by evaluation in the
form of outcomes. Self-evaluation, learner evaluation, organization evaluation and peer
evaluation are not new concepts. Evaluative processes are an integral part of all learning.
As early as 1989, Luker and Caress challenged the nurse as educator role. They made a
distinction between patient education and patient teaching, noting that the former is in advanced
practice and that not all nurses are prepared to be patient educators. The difference between the
specialist role and the generalist role in education remains largely unsubstantiated by evidence.
In the final analysis, application of knowledge that improves the health of individuals,
families and groups in the evaluative measure of learning.

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. With the explosion of interest in evidence-based nursing practice further
conceptually based research that identifies, describes, explains and predicts health behaviors of
the learner needs to be conducted.
 Healthy People 2010 (US Department of Health and Human Service, 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. This document sets the
stage for the nurse as educator to use theoretically based strategies to promote desirable health
behaviors of the learner.
Carter and Kulbok (2002), 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, certain populations have been underrepresented in
motivational research and that motivation may not be able to be effectively measured. They
challenge researchers and practitioners to carefully examine the role of motivation in influencing
health behaviors. 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. 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, motivation and health behaviors of the learner. In light of the
critical nursing workforce shortage and nursing faculty shortage, motivational factors should be a
paramount focus of research in nursing education as well as client education.