Nola.J.Pender Health Promotion Model 1982

Nola.J.Pender Health Promotion Model 1982
Nola.J.Pender was born in 1941 in Michigan. She earned diploma in nursing, B.S. in nursing, M.A. in human growth and development and PhD in Psychology and Education. She also did graduate level work in community health nursing at RUSH University, Chicago. The focus of her research was on health promotion. She did a research on ‘how people make decisions’ and based on this, initial version of Health Promotion Model (HPM) was published in 1982. She stated HPM as proposed a framework for integrating nursing and behavioral science perspectives as factors influencing health behaviors. The framework offered a guide for exploration of the complex biopsychosocial processes that motivate individuals to engage in behaviors directed towards the enhancement of health. The initial model had seven cognitive perceptual factors (importance of health, perceived control of health, definition of health, perceived health status, perceived self efficacy, perceived benefits and perceived barriers) and five modifying factors (demographic characteristics, biologic characteristics, interpersonal influences, situational influences and behavioral factors).
She identified the theoretical basis of the Health Promotion Model as drawing upon Social Cognitive Theory (Bandura, 1977). This theory emphasizes on self direction and self regulations are the abilities to direct and control one’s thinking and actions, perceptions of self efficacy involve one’s view of the personal ability to perform an identified set of actions. 

According to Pender et. al. (2006), Bandura identifies the following basic human capabilities;

• Symbolization - The ability to process and transform experience to create internal models to guide actions in the future.
• Forethought – The ability to anticipate possible consequences of potential actions and plan courses of action to achieve goals.
• Vicarious learning - The ability to obtain rules for selecting actions through observation of others without using trial and error.
• Self regulation- The ability to use internal standards and self evaluation to inspire and adjust behavior to external environment.
• Self reflection – The ability to consider one’s own thought process and change them.

Assumptions of Revised Health Promotion Model

• Persons seek to create conditions of living through which they can express their unique human health potential
• Persons have the capacity for reflective self awareness, including assessment o their own competencies
• Person’s value growth in directions viewed as positive and attempts to achieve a personally acceptable balance between change and stability
• Individuals seek to actively regulate their own behavior
• Individuals in all their bio-psychosocial complexity interact with the environment, progressively transforming the environment and being transformed overtime
• Health professionals constitute a part of the interpersonal environment, which influence on persons throughout their life span
• Self initiated reconfiguration of person environment interactive pattern is essential to behavior change

Health Promotion Model (Revised Variables) 

Individual characteristics and experiences

The Individual characteristics and experiences divided into prior related behavior and personal factors. Prior related behaviors are important, as it is best for predicting the future behavior. The direct effect of prior behavior is possibly that of habit formation, since each time a behavior is performed, the habit is strengthened. The personal factors are described as biological (age, BMI and strength), psychological (self esteem and self motivation) and socio cultural (race, education and socio economic status) factors.  

Behavior specific cognition and affect

This includes perceived benefits of action, perceived barriers to action, perceived self efficacy, activity related affect, interpersonal influences and situational influences, all of which leads to a commitment to a plan of action and consideration of immediately competing demands and preferences. 

Perceived plan of action may be intrinsic benefits (feeling better) and extrinsic benefits (time to socialize while practicing the target behavior). Perceived barriers to action mean the barriers which influence action directly by blocking that action or indirectly by decreasing any commitment to act. The perceived ability to achieve a behavior is perceived self efficacy of; Can I do it?, What will happen if I do it?.

Activity related effect- There are three components to this affect; the act related emotional arousal, the self related self acting and the context related environment in which behavior occurs. Interpersonal influences are the person’s thoughts or beliefs about the behavior, attitudes and beliefs of others and may or may not accurately reflect those behavior, attitudes and beliefs. Situational influences include the options that are perceived as being available, demand characteristics and environmental features. For example, ‘no smoking’ sign is intended to discourage smoking. Commitment to plan of action initiates the behavior, to carry out a specific plan of action at a given time and place. Immediate competing demands and preferences are alternative behaviors that intrude into consciousness as possible courses of action immediately prior to the intended occurrences of a planned health promoting behavior. 

The variables of Health Promtion Model have strengths and limitations. It is strength for use in practice because looking at all of the variables provides a more complete picture of the client. The limitation of the model is lacking of the spiritual factors.

Jean Watson Theory of Everything-The Ten Primary Carative Factors 1979 (USA)

Jean Watson Theory of Everything-The Ten Primary Carative Factors 1979 (USA)
Jean Watson was born in 1940, earned a baccalaureate degree in nursing, a master’s degree in psychiatric nursing and Ph.D. from the University of Colorado. Dr. Watson was named as distinguished professor, widely published author and recipient of numerous awards including six honorary doctoral degrees. Theoretical construction from Dr. Watson theory is used as a guide to many nursing academic programs.
The purpose of Watson’s theory is caring, promotion of health, preserving dignity, respecting the wholeness and interconnectedness of humanity. The theory pictures the nursing as a healing art and science with sacred relationships. It is the need of hour for nurses to identify the healing traditions for caring relationships at the societal and planetary level. There are fundamental differences in ways of being (ontology), knowing (epistemology) and doing (praxis) within the traditional versus human science paradigm. The purpose of traditional science is identification and prediction. Human science is concerned with the meaning of the lived experience. Professional nursing within a traditional science and biomedical model is focused on ‘doing’ by controlling and manipulating physical and behavioral parameters through specific actions and environments that maintain physiological and behavioral homeostasis.
Contents of the theory
Current dimensions of the theory are;

1. Expanded views of self and person; embodied spirit
2. Having caring healing consciousness
3. Forgiveness and surrender as highest level of consciousness
4. Unitary consciousness
5. Advanced caring and healing modalities
6. Nurse as sacred healing environment
7. Trans personal caring relationships
8. The specifications of trans personal caring relationships depends upon
9. Moral commitment and consciousness needed to protect human dignity
10. Ability of a nurse to identify other’s inner condition
11. Feel a union with the others
12. Ability to realize another’s condition of being in the world
13. Nurse’s own life history and previous experience
14. The caring and healing modalities potentiate harmony, wholeness, comfort and promote inner healing by releasing disharmony.
15. Caring occasion or caring moment occurs whenever nurse and others come together with their unique life histories in a human to human transaction and has the potential for collectively expanding the field of interconnectedness consciousness of the universe in a way that expands the universal field of harmony and wholeness.

Ten carative factors
It was identified by Watson in 1979 at the age of 39 years, as characterizing a caring relationship based upon the nurse’s conscious, moral commitment to each person in such a way that facilitates healing. The carative factors are;

1. Forming a humanistic altruistic system of values
2. Enabling and sustaining faith and hope
3. Being sensitive to self and others
4. Developing a helping-trusting and caring relationships
5. Promoting and accepting the expression of positive and negative feeling
6. Engaging in problem solving caring process
7. Promoting trans personal teaching and learning
8. Attending to supportive, protective, physical, mental, societal and spiritual environments
9. Assisting with gratification of basic human needs while preserving human dignity and wholeness
10. Allowing for and being open to existential phenomenological and spiritual dimensions of caring and healing that can not be fully explained successfully.

Jean Watson has played a major role in reorienting nursing from a bio-medical, mechanistic model to one of caring as a trans personal interactive process. Dr. Watson believes that the caring occasion or caring moment opens up a higher energy field with potential for healing beyond body and self, with potential movement toward greater harmony, wholeness, health and spiritual evolution.

Sister Callista Roy’s Adaptation Model 1979 (USA)

Sister Callista Roy’s Adaptation Model 1979 (USA)
Sister Callista Roy was born on 1939, earned her B.S. in nursing from Los Angeles, M.S. in nursing and her doctorate in Sociology in 1977 from the University of California. She is the author, co author, professor and nurse theorist and known world wide for Roy Adaptation Model.  Her contributions to nursing are an Adaptation Model, Essentials of the Roy Adaptation Model, Theory Construction in Nursing, The Roy Adaptation Model: The Definitive Statement, Roy Adaptation Model Based Research, Twenty Five Years of Contributions to Nursing Science and Nursing Knowledge Development and Clinical Practice.
The Roy Adaptation Model has captured interest and respect since 1964 and she published her work in 1970 at the age of 31 years. She defined adaptation as ‘the process and outcome where by thinking and feeling persons, as individuals or in groups, use conscious awareness and choice to create human and environmental integration.’

The four major concepts of the RAM include:

1. Human as adaptive systems
2. The environment
3. Health
4. The goal of nursing

Human adaptive system
Roy conceptualizes the human system in a holistic perspective, which means the aspect of unified meaningfulness of human behavior in which the human system is greater the sum of individual parts.
Adaptation
The human adaptive system has input coming from the external environment as well as with in the system. Roy identifies inputs as stimuli and adaptation level. Stimuli are classified into three: focal, contextual and residual. The stimulus most immediately confronting the human system is the focal stimulus. Contextual stimuli are from the human systems internal and external world. Residual stimuli are those internal and external factors are unclear.
Adaptation level is the combining of stimuli that represents the condition of life process for the human adaptation system. The three levels defined by Roy are integrated, compensatory and compromised. Integrated process is present when the adaptation level is working as a whole to meet the needs of the human system. The compensatory process occur when the human’s response system have been activated and compromised process occur when the compensatory and integrated process are not providing for adaptation. 

Roy presents a unique nursing concept of control mechanisms:  the regulator and cognator.
The regulator subsystem has the components of input, internal process and output. Target organs and tissues under endocrine control produce regulator output response. Cognator control process is related to higher brain functions of perception, learning, judgment and emotion.

Roy categorizes family, group and collective system control mechanisms as the stabilizer and the innovator system. It suggests two goals: stabilization and change. Stabilizer process is those of established structure, values and daily activity where the work of the group is done and the group contributes to the general well being of society. The innovator subsystem identifies structure and processes that promotes change and growth. 

Four adaptive models
The coping processes, cognator-regulator and stabilizer-innovator promote adaptation in human adaptive system. Roy has identified four adaptive modes as categories for assessment of behavior resulting from cognator-regulator coping mechanisms in persons or stabilizer-innovator coping process in groups. These adaptive modes are

1. Physiological –physical
2. Self concept- group identity
3. Role function
4. Interdependence

Physiological –physical mode
The physiological mode represents the human system is physical responses and interaction with the environment. This is associated with fluid, electrolyte, elimination, nutrition, rest, neurologic function and endocrine function. The physical mode related to basic operating resources such as participants, physical facilities and fiscal resources.
Self concept- group identity mode
Self concept consists of a person’s beliefs about himself or herself at any given time. It has two components: physical self and personal self. Physical self includes body sensation and body image. Personal self includes self ideal, moral, ethical and spiritual belief. The group identity mode consists of interpersonal relationship, group self image, social milieu and culture.
Role function mode
It consists of a set of expectations of how a person in a particular position will behave in relation to a person who hold another position. It includes functions of the staff, decision making, initiative and delegation of the work to maintain in order to fulfill the expected responsibilities.
Interdependence mode
The mode focuses on the giving and receiving of love, respect and value with significant others and support systems. The underlying need of the mode is to nurture relationships.
Environment
She defined environment as all conditions that surround and affect the development and behavior of humans as adaptive systems, with particular consideration of person and earth resources.

The Roy Adaptation Model identifies the essential concepts relevant to nursing as the human adaptive system, the environment, health and nursing. The model suggests that nurses alter, increase, decrease, remove or maintain focal stimulus or if that is not possible, change the contextual stimuli so that the purposeful adaptation and transformation between the person and environment is promoted.

Betty Newman’s system model 1972 (USA)

                                           

Betty Newman’s system model 1972 (USA)
Betty Newman’s was born in 1924, received B.S. in Public Health Nursing and M.S. in public health from the University of California. She has practiced as bed side nurse and head of the department in various hospitals. Her contributions are lecturer, author, teacher and consultant in nursing.
The Newman’s system model was developed in 1970 with an overview of the physiological, psychological, socio cultural and developmental aspects of human beings. The model was published in 1972 in nursing research at the age of 48 years. The Newman’s system model diagram presents the major aspects such as basic structure, energy resources (physiological, psychological, socio cultural, developmental and spiritual variables), line of resistance, normal line of defense, flexible line of defense, stressors, reaction, primary, secondary and tertiary prevention, intra, inter and extra personal factors and reconstitution. The environment, health and nursing are inherent parts of the model. The client is represented in the diagram as a basic structure, surrounded by a series of concentric circles and is a living and open system. 

Basic structure and energy resources
It is made up of basic survival factors common to all. It includes physiological, psychological, socio cultural, developmental, genetic etc. Newman identifies system stability as occurring when the energy exchanges with the environment occur with out disrupting the characteristics of the system.
Client variables
She views the individual client considers the variables. The physiological (structure and function of the body), psychological (mental process and relationships), socio cultural (social and cultural expectations), developmental (growth and developmental) and spiritual (spiritual beliefs) variable.
Line of resistance
It protects the basic structure and become activated when the normal line of defense is invaded by environmental stressors.
Normal line of defense
It represents stability over time. When it is invaded, the client system reacts.
Flexible line of defense
It serves as a cushion and absorbs shock. It can be altered over a short period of factors such as inadequate nutrition, lack of sleep or in a danger situation.
Environment
It defines the environment as all the internal or external factors or influence that surrounds the client. The internal environment exists with in the client system and external environment exits in the outside the client system. She developed a third environment called created environment, which is intra, inter and extra personal environment.
Stressors
She classified stressors as intra, inter and extra personal in nature. Intra personal stressors are occurred with in the client system boundary, extra personal stressors occur outside the system boundary. Inter personal stressors occur outside the client system boundary but are proximal to the system.
Health
She identifies health as optimal system stability, harmony among the five variables or the optimal state of wellness at a given time.
Reaction
She discusses the reaction as negentropy and entropy.
Prevention as intervention
Primary prevention occurs before the system reacts to a stressor, includes health promotion strategies such as immunization, health education and life style changes. Secondary intervention occurs after the system reacts to a stressor. It includes appropriate treatment of symptoms. For example, use of analgesics to decrease pain. Tertiary prevention may begin at any point after system stability has begun to be reestablished. An example of tertiary prevention is participation in cardiac rehabilitation program after a cardio vascular surgery.
Reconstitution
It defined the return to and maintenance of system stability. It depends on successful mobilization of client resources to prevent further reaction to the stressors and represents a dynamic state of adjustment.
Newman also supports nursing as part of the model. The aim of nursing to help the client system attains, maintain or retain system stability. It can be achieved through assessment of actual and potential effects of stressor invasion and assist the client for optimal wellness through primary, secondary and tertiary modes of prevention.

Dorothea Orem Self Care Deficit Theory 1971 (USA)

Dorothea Orem Self Care Deficit Theory 1971 (USA)
Dorothea Elizabeth Orem born on 1971 received her diploma in nursing from Providence Hospital School of Nursing, her Bachelor of Science and Master of Science in nursing education from Catholic University of America. She received several honorary degrees and national awards including Catholic University of America’s Alumni Association Award for nursing theory.
Orem (2001) states her general theory as follows: “Nursing has as its special concern man’s need for self care action and provision and maintenance of it on a continuous basis in order to sustain life and health, recover from disease and injury and cope with their effects. The condition that validates the existence of a requirement for nursing in an adult is the health associated absence of the ability to maintain continuously that amount and quality of self care that is therapeutic in sustaining life and health, in recovery from diseases or injury or in coping with their effects. With children, the condition is the inability of the parent or guardian as associated with the child’s health state to maintain continuously for the child the amount and quality of care that is therapeutic”.
Orem developed self care deficit nursing theory, which is composed of three interrelated theory:

1. Theory of self care
2. Theory of self care deficit
3. Theory of nursing system

Under these three theories, there are six central concepts and one peripheral concept:

1. Self care and dependent care
2. Self care agency and dependent care agency
3. Therapeutic self care demand
4. Self care deficit
5. Nursing agency
6. Nursing system

The peripheral concept is basic conditioning factors
Theory of self care
The concepts are self care, self care agency, self care requisites and therapeutic self care demand. Self care is the activities that individuals do it for themselves. Self care agency is the human’s acquired power and capabilities to engage in self care and is affected by basic conditioning factors such as age, gender, health state and pattern of living etc. The therapeutic self care demand is the total of activities needed over a period of time to meet the person’s known requirements for self care. Self care requisites are the reasons self care activities occur and are an expression of the hoped for results. It is categorized into three: universal, developmental and health deviation. Universal requisites means activities of daily living such as intake of air, water, food, rest etc. Developmental self care requisites are specific to the process of growth and development during life cycle changes. Health deviation self care requisites are related to change in human structure due to genetic variation or other defects. In the theory of self care, Orem explains what is meant by self care and list the various factors affect it.
The theory of self care deficit
When therapeutic self care demand exceeds self care agency, a self care deficit exists and nursing is required. Nursing may be necessary when individuals need to carry out complex self care or during illness or injury. Orem identifies the following five methods of helping that nurses may use:

1. Acting for or doing for another
2. Guiding and directing
3. Providing psychological support
4. Providing an environment to support personal development
5. Teaching

In clinical nursing practice, Orem (2001) has identified work operations include:

• Entering into and maintaining interpersonal relationships
• Design, plan and implement nursing care
• Respond to patient requests
• Coordinate nursing care
• Continue the patient care
• Use multisectoral approach
• Discharge the patient from nursing care

The theory of nursing systems
It includes nursing agency and nursing system. Nursing agency is a complex attribute of mature or maturing people educated and trained as nurses that enables them to act, to know and to help others meet their therapeutic self care demands. It is a power that nurse has to engage in effective nursing practice. Orem has identified three classification of nursing system to meet the self care requisites of the patient. The design and elements of the nursing system make four elements: the extent of the responsibility of the nurse in the health care situation, the various roles of the people in the situation, the reason for these being a nurse patient relationship and the actions to be carried out by the nurse and patient to meet therapeutic self care demand. These nursing systems are wholly compensatory, partly compensatory system and supportive-educative system.
Wholly compensatory system includes:

• Accomplishes patient’s self therapeutic care
• Compensates for patient’s inability to engage in self care
• Supports and protects the patient

Partly compensatory system includes:

• Performs some self care measures for patient
• Compensates for self care limitation of patient
• Assist the patient as required
• Performs some self care measures
• Regulates self care agency
• Accepts care and assistance from nurse

Supportive- educative system includes:

• Accomplishes self care
• Regulates the exercise and development of self care agency

To conclude, Orem indicates that nursing service to families and patients generally require some combination of aspects of two nursing systems, namely, the partly compensatory and supportive and educative nursing systems. It is applicable in nursing care with individuals in clinical side and community health practice.