Middle-Range Theories: Nola J. Pender’s Health Promotion Model
Within constantly broadening scope of nursing theories, middle-range theories take a specific place. To be more precise, these clarification research paradigms attempt to bridge the knowledge gap between grand theories of nursing and the areas of nursing that are yet to be explained. In accordance with Smith and Liehr, “with expansion of middle-range theories, nursing is enriched” by “elaborating more concrete concepts and relationships, such as uncertainty, self-efficacy, meaning,” to name a few. The paper analyzes the health promotion model (HPM) developed by Nola Pender in light of the author’s and theory’s background, key concepts on the basis of which HPM operates, along with its overall evaluation and application.
Theory and Author’s Background
The developer of HPM, Nola Pender, is a professor Emerita of University of Michigan and a distinguished professor of Loyola University of Chicago who has in-depth knowledge in a number of specializations in nursing field supported with appropriate academic degrees. To illustrate, the year of 1965 was the time when the scholar completed her master’s degree in human development at Michigan State University that enabled her to realize significance of health in human lifespan and start a research program in adolescents and children. What is more, at the Northwestern University, Pender pursued a PhD program in psychology and education which she finished by 1969. Another step in expanding her educational accomplishments was a master’s work exploring the community health nursing which she completed at Rush University. Hence, Pender obtained multidimensional educational background in the field of interest.
Moreover, underpinning of the HPM has had a personal component. On the one hand, Pender collaborated with her husband, a professor in business and economics, in terms of investigating the issues of interconnectedness of nursing, healthcare in general, and economics. On the other hand, the fact that she became a mother of two children was another aspect that enticed her to “learn more about optimizing human health” . As a result, all previous accomplishments were incorporated in her HPM that was initially introduced in 1982 as well as revisited and revised in 1996 on the grounds of the empirical evidence obtained as a result of testing the theory in practice. Apart from the theorized postulates of the HPM in the article “A Conceptual Model for Preventive Health Behavior,” the theorist and her colleagues, as well as independent researchers, completed a series of studies for collecting primary evidence and confirmation of the validity of these assumptions. Drawing upon Smith and Liehr, approximately 40 studies “tested the predictive capability of the model for health-promoting lifestyle, exercise, nutrition practices, use of hearing protection, and avoidance of exposure to environmental tobacco smoke”. For example, Srof and Velsor-Friedrich have reviewed the constituents of HPM and the supporting theoretical background in connection with the social cognitive theory with adolescents as a primary target audience. With all these data collected during the last 27 years, the validity and credibility of the arguments by Pender in favor of disease prevention and health promotion were verified.
Among the initial motivating factors that encouraged Pender to develop a theory were “considerations on how people think and how a person’s thoughts motivate behavior” with respect to healthcare sector and health in general. In this way, the theorist aimed to help nurses in determining the key individual characteristics of health behaviors in order to develop appropriate counseling strategies and promote healthy lifestyles as well as modify a patient’s health behavior. As soon as these models will be effectively created and implemented, such a circumstance will likely to result in win-win outcomes for all parties involved. To be more precise, patients will be healthier for long; hospitals will promote healthier community lifestyles, thus, will have more cost-efficient operations, while the general aims of healthcare system will be achieved with most favorable outcomes. Therefore, HPM can be considered as a suitable multidimensional approach towards addressing the complex problems of healthcare system as a whole in terms of disease prevention.
Given the above rationale of HPM conceptualization and development, it is evident that the theory was formulated by means of deductive reasoning. Smith and Liehr have explained that “movement from the upper philosophical rung to the theoretical and then empirical is deductive reasoning” . Indeed, Pender has developed her middle-range nursing theory in such a way. According to the scholar, the HPM has both philosophical and theoretical core. From the philosophical perspective, the researcher has explored the essence of reciprocal interaction world view that asserts that humans are holistic, though their parts may be thoroughly studied in the “context of the whole”. In particular, this assumption allows to interpret human life as their interaction with external environment whereas they need to satisfy their needs and achieve goals accordingly.
From the theoretical standpoint, Pender has identified expectancy value and social cognitive theories as integral parts of her HPM. On the one hand, expectancy value theory encourages individuals for action and goals’ achievement as soon as these enable one to have individual value for a person. In this light, ample health is characterized not merely by the absence of disease or ailment but also by “a general and holistic state of well-being, healthy actions of an individual and a balanced, fulfilling way of life” (Health Promotion Model [HPM] Official Website, n.d.). On the other hand, social cognitive theory interrelates human ideas, thoughts, and behavior in the environmental context, meaning that a change in thinking will eventually lead to change in behavior. It follows that HPM actually stems from philosophical and theoretical underpinnings as appropriate for deductive reasoning. At the same time, the fact that the process of theorizing of health promotion and disease prevention ideas by Pender was followed by obtaining the affirmative supporting empirical evidence from the practical research demonstrates additional relevance of HPM to deductive reasoning.
While HPM ascertains that a nurse should identify and clarify health factors for each individual specifically, the model is focused on 8 core beliefs. Initially, they were theorized by the developer, though primary evidence allowed to make adjustments in their interpretation and significance. Therefore, the concepts were theoretically defined, while they were operationally supported and refined. First, a notion of a person is to be considered whereas one is involved in reciprocal relationship and interaction with the environment on the grounds of individual features and life experiences. Second, environment is regarded as possible facilitator of human health behavior in light of physical, social and cultural context. Third, nursing is a collaborative force that is capable to encourage an individual to change one’s health behavior within the multifaceted environmental domain and entice one to achieve balanced well-being. Fourth, health is another vital concept in the scope of HPM. Regardless of that followers of Pender have expanded the understanding of health to family health and that of community, the conceptualist of HPM has provided a rather individual-focused notion of health at large. Specifically, the term is defined as “evolving life experience” as well as “actualization of inherent and acquired human potential through goal-directed behavior, competent self-care, and satisfying relationships with others”. Fifth, illness in one more important issue to consider since this phenomenon is likely to undermine a person’s well-being and aspiration to maintain good health. The concepts altogether have been consistently used in the context of the theory, though individual researchers have proposed certain expansions or clarifications of the terms, such as aforementioned notion of health with relation to an individual, family and community at large.
Apart from the explicit definitions of the above core concepts that are foundation of the model, 3 more grouped constituents of HPM should be regarded. These components include individual characteristics and experiences, behavior-specific cognitions and affect, as well as health-promoting behavior as health promotion outcome. The first category of HPM components determines whether an individual experienced related health behavior earlier and personal factors that are likely to either contribute to health improvement or have negative impacts. The second category considers perceived benefits of making a change, barriers to these transformations, perceived self-efficacy, and activity-related effects, to list a few. Finally, one more crucial element of HPM is development if health-promoting behavior as a result of nurse-to-patient relationship and interaction.
On the grounds of the clear definitions of all the aforementioned concepts and beliefs, it is evident that HPM aims to use these means effectively and manipulate them in order to achieve the most positive outcomes in health promotion and disease prevention. For instance, as aptly noted by Atkins, “health promotion focuses on increasing levels of wellbeing by increasing activities which result in improved health, optimized functional ability, and better quality of life through lifespan”. Awareness of prior behavior allows to discover the individual’s beliefs and motivators in health behavior. In this regard, a nursing practitioner assists a patient in understanding one’s individual factors related to “an individual’s lifestyle, mindset, and psychological health, social and cultural aspects as well as biological factors”. A person is likely to willingly change one’s health behavior as soon as a course of action is close to one’s personal beliefs and values when barriers are overcome effectively.
This collaborative and shared knowledge can become a substantial foundation for determining the best approaches for obtaining good health, improved functional abilities, and higher-level life quality for patients. In light of perceived self-efficacy, one can develop the sense of self-care, “including experience, skill, motivation, culture, confidence, habits, function, cognition, support from others, and access to care”. As soon as these notions are related and closely associated with a positive emotional stance, an individual is likely to be highly committed towards making a positive change and improving one’s health outcomes and well-being. At the same time, the issue of environment, such as family members and friends, can be either a facilitator of health promotion or have a detrimental effect on one’s health by impacting the individual’s commitment to implementation of the change strategy. In any case, in-depth awareness as well as productive collaboration with a nursing practitioner in the scope of the theory can be useful tools for enhancement of patient’s health and well-being.
In accordance with the theoretical background of HPM, Pender has identified and explicated 7 key assumptions which nurses can use in order to assist a patient in health promotion and disease prevention. These assumptions are as follows:
- Individuals are in endless quest for good health by means of development and improvement of appropriate living conditions.
- Humans are likely to self-assess and self-reflect on their health-related capacities.
- Persons try to seek positive directions for improvement of their health and well-being.
- They aim to manage their health behavior on their own.
- Individuals are likely to transform their environment as well as transform themselves under the impact of their environments, including its social, cultural and physical characteristics.
- Healthcare practitioners are also a part of individual’s environment who are likely to affect their health and well-being throughout their lifespan.
- As soon as a person reconsiders the specificities of one’s interaction with the environment, they may change their health behavior.
Therefore, HPM is based on the assumption that a patient who is well-aware of one’s individual health-related specificities can be empowered to change their lifestyle for healthier one and improve their health accordingly.
Despite the fact that there is no specific indication to 4 core components of nursing metaparadigm in HPM, the discussed middle-range theory is thoroughly based on these notions. In particular, the metaparadigm of nursing practice comprises of such elements as person, environment, health and nursing components. On the grounds of the conducted analysis, it is explicitly showed that all these four components are intertwined within the developed model of health promotion and disease prevention. While person and one’s individual features are foremost considered prior to developing any potential interventions in this respect, thorough and holistic analysis of person’s environment is of great significance for ensuring that all crucial factors and barriers are taken into account for this purpose. Similarly, health component is critical for both the metaparadigm and HPM.
However, the interpretation of this element of patient’s care differs in the two domains. On the one hand, regardless of that HPM defines this constituent as a crucial element of human well-being, the notion is greatly based on individual health-related capacities. The issues relate to multiple characteristics of one’s well-being and environmental factors that are likely to either positively or negatively impact on an individual’s health throughout their lifespan. On the other hand, generalized understanding of health in light of metaparadigm also determines the extent of person’s accessibility to healthcare means and tools in order to maintain the balance an individual is likely to obtain in the intersection of all health-related factors. Hence, while HPM has incorporated this component of metaparadigm, it seems a little narrowed as compared to the general definition of health in the metaparadigm.
Finally, nursing is also a vital part of HPM, though, again, its implications are rather narrowed in HPM as compared to metaparadigm. With respect to Pender’s interpretation, nursing is referred to as “collaboration with individuals, families and communities to create the most favorable conditions for the expression of optimal health and high-level well-being”. In contrast, the definition of nursing component in the metaparadigm context implies a much broader scope and more clarity in terms of operability of this concept. To be more precise, scholars have emphasized a necessity of application of the highest-level knowledge and skills, technologies, interprofessional collaboration, as well as professional communication as part of this domain. Of course, the above issues may be boldly called specifications of nursing roles. Nevertheless, all four critical constituents of the metaparadigm of nursing practice have become the core of HPM. This fact evidences that the theory thoroughly corresponds to the key tasks and competencies set before these healthcare practitioners with clearer emphasis on nurse-to-patient as well as nurse-to-wider-community collaboration rather than interprofessional shared knowledge.
In any case, based on the conducted analysis of HPM, the middle-range theory seems clear and comprehensive. Even without in-depth awareness in the field, it is quite understood that all that an individual needs to make a change in one’s lifestyle and balance one’s health and well-being is to (a) know own background and environment specificities and (b) address a knowledgeable nurse for assistance in terms of development of possible intervention strategies. All stages of change are briefly explained by the developer. Moreover, there is even a clear guide for specified and most common chronic health conditions, such as addressing sedentary lifestyle through increased physical activity, to provide an example.
In general, HPM is well-thought-out in light of provision clear guideline for a nurse to follow and organize one’s actions appropriately. Foremost, as it was previously noted, the discussed middle-range approach to bridging theory and practice in the health promotion and disease prevention is both well-theorized and substantially researched. Thus, the theory has sufficient background for development of evidence-based practice. In this respect, scholars propose a set of critical assessment sheets for a range of specific health concerns and diseases. For instance, Pender’s HPM manual has critical assessment for health promotion plans in increasing physical activity and improving nutrition along with sample interventions to be used as patterns for individual change strategies. What is more, understanding of key concepts and components of the model are of great value for a nurse. A practitioner can know at hand what to focus on in light of a particular patient as well as determinants of one’s health and well-being given the guideline developed by the scholar and her followers. Therefore, HPM has offered an easy-to-follow approach towards empowerment a patient for a change in one’s lifestyle and health behavior by means of nurse’s involvement.
The application of the analyzed theory in my nursing area can be twofold. On the one hand, the fact that HPM has been already tested in cardiology is a great incentive in my current practice as a nurse in this field. Undoubtedly, cardiologic diseases are among the most preventable health conditions. Thus, HPM Hayman, Berra, Fletcher, and Miller have emphasized a key role of nurses in the sphere. Particularly, they become key actors in “managing single and multiple risk factors, such as hypertension, smoking, lipids, and diabetes; the sequelae of chronic conditions” and “programs in primary care, worksites, and cardiac rehabilitation,” to list a few. Rehabilitation process after cardiac diseases also requires lifestyle changes. For this reason, HPM would be a great incentive in enhancement of patients’ health from this perspective.
On the other hand, emergency care field as another aspect of my specialty can win with application of HPM as well. Specifically, the sphere lacks a distinct and one-suits-all care model. At the same time, patient health education and self-education through HPM may be a great contributing factor towards repetitive traumas and injuries through their improved health behaviors and lifestyles. By holistic and collaborative patient’s lifestyle analysis according to HPM assessment tools, self-education of the patients will enhance their self-efficacy and make them value their lives and health. Therefore, with a nurse’s empowerment, expectancy value in light of social cognitive values will entice patients to improve their health behaviors and seek for health and well-being balance with positive long-term outcomes.