The Health Promotion Model: Nola J. PenderBackgroundNola J. Pender was born in 1941 in Lansing, Mich b45c23a25b20a600b989ccb968e796d8.docx
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The Health Promotion Model: Nola J. Pender
Nola J. Pender was born in 1941 in Lansing, Michigan. She graduated in 1962 with a diploma in nursing. In 1964, Pender completed a bachelor’s of science in nursing at Michigan State University. By 1969, she had completed a doctor of philosophy in psychology and education. During this time in her career, Pender began looking at health and nursing in a broad way, including defining the goal of nursing care as optimal health.
In 1975, Pender published a model for preventive health behavior; her health promotion model first appeared in the first edition of the text Health Promotion in Nursing Practice in 1982. Pender’s health promotion model has its foundation in Albert Bandura’s (1977) social learning theory (which postulates that cognitive processes affect behavior change) and is influenced by Fishbein’s (1967) theory of reasoned action (which asserts that personal attitudes and social norms affect behavior).
Pender’s Health Promotion Model
McCullagh (2009) labeled Pender’s health promotion model as a middle-range integrative theory, and rightly so. Fawcett (2005) decisively presented the difference between a conceptual model for nursing and a model for middle-range theory. A model for middle-range theory is usually a graphic representation or schematic diagram of a middle-range theory. McCullagh’s (2009) rationale for labeling Pender’s model a middle-range integrative theory is that it portrays the multidimensionality of persons interacting with their interpersonal and physical environments as they pursue health while integrating constructs from expectancy-value theory and social cognitive theory with a nursing perspective of holistic human functioning (Pender, 1996). With the third edition of Health Promotion in Nursing Practice (1996), Pender revised the health promotion model significantly. This revised model is the subject of the discussion in this chapter.
Pender’s health promotion model includes three major categories: (1) individual characteristics and
experiences, (2) behavior-specific cognitions and affect, and (3) behavioral outcome. Each of these categories will be considered here separately.
The first category includes each person’s unique personal characteristics and experiences, which affect that individual’s actions. Significant components within this category are prior related behavior and personal factors. Prior related behavior is important in influencing future behavior. Pender proposed that prior behavior has both direct and indirect effects on the likelihood of engaging in health-promoting behaviors. In particular, past behavior has a direct effect on the current health-promoting behavior through habit formation: Habit strength increases each time a behavior occurs. Prior behavior is proposed to indirectly influence health-promoting behavior through perceptions of self-efficacy, benefits, barriers, and activity-related affect or emotions (Pender, Murdaugh, & Parsons, 2006). Personal factors include biological factors such as age, body mass index, pubertal status, menopausal status, aerobic capacity, strength, agility, or balance; psychological factors include self-esteem, self-motivation, and perceived health status; and sociocultural factors include race, ethnicity, acculturation, education, and socioeconomic status. Some personal factors are amenable to change, whereas others are immutable (Pender et al., 2006).
The second category encompasses behavior-specific cognitions and affect, which serve as behavior-specific variables within the health promotion model. Behavior-specific variables are considered to have motivational significance. In the health promotion model, nursing interventions target these variables because they are amenable to change. The behavior-specific cognitions and affect identified in the health promotion model include (1) perceived benefits of action, (2) perceived barriers to action, (3) perceived self-efficacy, and (4) activity-related affect. Other cognitions fall into the category of interpersonal influences and situational influences. Sources of interpersonal influences on health-promoting behaviors include family, peers, and healthcare providers. Interpersonal influences include norms, social support, and modeling; they shape the person’s tendency to participate in health-promoting behaviors. Situational influences on health-promoting behavior include
perceptions of available options, demand characteristics, and aesthetic features of the environment. Within Pender’s model, nursing plans are tailored to meet the needs of diverse patients based on assessment of prior behavior, behavior-specific cognitions and affect, interpersonal factors, and situational factors (Pender et al., 2006, pp. 54–56).
The third category within Pender’s model is the behavioral outcome. Commitment to a plan of action marks the beginning of a behavioral event. This commitment propels the person into the behavior unless that action is confounded by a competing demand that cannot be avoided or a competing preference that is not resisted. Interventions in the health promotion model focus on raising consciousness related to health-promoting behaviors, promoting self-efficacy, enhancing the benefits of change, controlling the environment to support behavior change, and managing the barriers to change. Health-promoting behavior, which is ultimately directed toward attaining positive health outcomes, is the product of the health promotion model (Pender et al., 2006, pp. 56–63).
Major Concepts of Nursing According to Pender
The person in the health promotion model refers to the individual who is the primary focus of the model. In Pender’s model, each person has unique personal characteristics and experiences that affect subsequent actions. It is recognized that individuals learn health behaviors within the context of the family and the community, which explains why the model for assessment includes components and interventions at the family and community levels, as well as the individual level (Pender, Murdaugh, & Parsons, 2002, 2006). This is taken a step further in the latest edition (Pender, Murdaugh, & Parsons, 2011), in which the term client refers to individuals, families, and communities who are all viewed as active participants in health promotion.
In the health promotion model, the environment encompasses the physical, interpersonal, and economic circumstances in which persons
live. The quality of the environment depends on the absence of toxic substances, the availability of restorative experiences, and the accessibility of human and economic resources needed for healthful living. Socioeconomic conditions such as unemployment, poverty, crime, and prejudice have adverse effects on health, whereas environmental wellness is manifested by balance between human beings and their surroundings (Pender et al., 2006, p. 9; Pender et al., 2011, p. 8).
Health is viewed as a positive high-level state. According to Pender, the person’s definition of health for himself or herself is more important than any general definition of health (Pender et al., 2006; Sakraida, 2010). Health is viewed in the context of health promotion and disease prevention. Health promotion is behavior that is motivated by a desire to increase well-being and optimize human health potential, whereas disease prevention or health protection is behavior motivated by a desire to actively avoid illness, detect illness early, or maintain functioning within the constraints of illness (Pender et al., 2011, p. 5). Health promotion is viewed as a multidimensional concept that includes the dimensions of the individual, the family, the community, socioeconomic status, cultural factors, and environmental factors (Pender et al., 2011, pp. 6–8).
The role of the nurse in the health promotion model revolves around raising consciousness related to health-promoting behaviors, promoting self-efficacy, enhancing the benefits of change, controlling the environment to support behavior change, and managing the barriers to change (Pender et al., 2006, pp. 57–63). A major function of the APN role is the focus on health promotion. This model serves as a significantly pragmatic process for APNs to use to encourage health-promoting behaviors by patients and to address the benefits of change.
Analysis of the Health Promotion Model
The analysis and critique presented here comprise an examination of assumptions
and propositions, as well as the analysis of clarity, simplicity, generality, empirical precision, and derivable consequences of Pender’s health promotion model.
Assumptions of the Health Promotion Model
Assumptions of the health promotion model reflect both nursing and behavioral science perspectives. The seven major assumptions emphasize the active role of the patient in shaping and maintaining health behaviors and in modifying the environmental context for health behaviors:
1. Persons seek to create conditions of living through which they can express their unique human potential.
2. Persons have the capacity for reflective self-awareness, including assessment of their own competencies.
3. Persons value growth in directions viewed as positive and attempt to achieve a personally acceptable balance between change and stability.
4. Persons seek to actively regulate their own behavior.
5. Persons in all their biopsychosocial complexity interact with the environment, both progressively transforming the environment and being transformed over time.
6. Health professionals constitute a part of the interpersonal environment, which influences persons throughout their life span.
7. Self-initiated reconfiguration of person–environment interactive patterns is essential for behavior change (Pender et al., 2002, p. 63).
Propositions of the Health Promotion Model
The health promotion model is based upon 14 theoretical propositions. These theoretical relationship statements provide a basis for research related to health behaviors:
1. Prior behavior and inherited and acquired characteristics influence health beliefs, affect, and enactment of health-promoting behavior.
2. Persons commit to engaging in behaviors from which they anticipate deriving personally valued benefits.
3. Perceived barriers can constrain commitment to action (a mediator of behavior), as well as actual behavior.
4. Perceived competence or self-efficacy to execute a given behavior increases the likelihood of commitment to action and actual performance of behavior.
5. Greater perceived self-efficacy results in fewer perceived barriers to a specific health behavior.
6. Positive affect toward a behavior results in greater perceived self-efficacy, which can, in turn, result
in increased positive affect.
7. When positive emotions or affect are associated with a behavior, the probability of commitment and action are increased.
8. Persons are more likely to commit to and engage in health-promoting behaviors when significant others model the behavior, expect the behavior to occur, and provide assistance and support to enable the behavior.
9. Family, peers, and healthcare providers are important sources of interpersonal influence who can increase or decrease commitment to and engagement in health-promoting behavior.
10. Situational influences in the external environment can increase or decrease commitment to or participation in health-promoting behavior.
11. The greater the commitment to a specific plan of action, the more likely health-promoting behaviors will be maintained over time.
12. Commitment to a plan of action is less likely to result in the desired behavior when competing demands over which persons have little control require immediate attention.
13. Commitment to a plan of action is less likely to result in the desired behavior when other actions are more attractive and thus preferred over the target behavior.
14. Persons can modify cognitions, affect, and the interpersonal and physical environments to create incentives for health actions (Pender et al., 2002, pp. 63–64).
Analysis: Clarity, Simplicity, Generality, Empirical Precision, and Derivable Consequences
Pender’s health promotion model was formulated using inductive reasoning with existing research, which is a common approach to the building of middle-range theories. The research used to derive the model was based on adult samples that included male, female, young, old, well, and ill populations; this design allows the model to be generalized easily to adult populations (Sakraida, 2010).
The health promotion model is simple to understand, because it uses language familiar to nurses. The concept of health promotion is also popular in nursing practice and, therefore, is a practical principle for APNs’ use. The relationships among the factors
are linked, and relationships are identified and consistently defined. Considering all of these factors, it is not difficult to see why Pender’s model is popular with practicing nurses and is frequently used as a tool in research. Nevertheless, it has not been used extensively in nursing education, where the emphasis is on illness care in acute care settings (Sakraida, 2010).
Pender identified health promotion as a key global goal for the 21st century (Pender et al., 2011) and, through development of the health promotion model, has assisted in the delineation of the role of nursing in meeting that goal. Although Pender has now retired, her work on the health promotion model continues. Pender views the nurse’s role in health promotion as more important than ever considering existing health disparities and the challenges of our current healthcare system (Pender et al., 2011). The current scenario of increasing costs for health care associated with episodic illness treatment increases in chronic, preventable conditions within the population, and the focus on managing healthcare costs provide ample incentive to further explore the concepts of the health promotion model as APNs strive to improve health outcomes in patient populations.
Although the four nursing models described in this chapter were conceived by four very different nurses whose careers spanned more than a century, they share a common thread: All place emphasis on the function of nursing practice in relation to health outcomes. For Nightingale, the function of nursing is to alter the environment to allow for action on the person by natural laws of health; for Henderson, the function of nursing is to assist the person to perform activities to gain independence; for Johnson, the function of the nurse is to impose external regulatory mechanisms in order to facilitate restoration of system balance; and for
Pender, the nurse functions to raise consciousness, promote self-efficacy, and control the environment to allow for behavior change resulting in high-level health. All four of these nursing models also conceptualize the goal of nursing care as a restoration of the health of the patient, however differently the concept of health—or, for that matter, the concept of the patient—may be defined in their respective theories.