Nola Pender: Health Promotion Model (Theory Guide)

Most nursing models start with illness. Pender's starts before it. Nola J. Pender (1941–present) developed the Health Promotion Model in 1982 to map the nurse's role in helping patients prevent illness through self-care and behavior change. She began studying health-promoting behavior in the mid-1970s, published the model in 1982, and is a professor emeritus of nursing at the University of Michigan and a Living Legend of the American Academy of Nursing.

Biography of Nola J. Pender

Early Life

Pender was born on August 16, 1941, in Lansing, Michigan, to parents who pushed education for women. She was seven years old when she watched nurses care for her hospitalized aunt. That moment set her toward caring for others, and her goal became helping people care for themselves.

Education

She entered the School of Nursing at West Suburban Hospital in Oak Park, Illinois, and earned her nursing diploma in 1962. In 1965 she received a master's degree in human growth and development from the same university. She then went to Northwestern University in Evanston, Illinois, for a Ph.D. in psychology and education in 1969; her dissertation studied developmental changes in the encoding process of short-term memory in children. Years later she completed master's-level work in community health nursing at Rush University.

Career and Appointments

In 1962 Pender began on a medical-surgical unit and then a pediatric unit in a Michigan hospital. For 40 years at Michigan State University she taught undergraduate and graduate students and mentored many postdoctoral candidates.

She directed studies of her Health Promotion Model with adolescents and adults. With her research unit she developed Girls on the Move, which measures intervention results in using the model to encourage young people toward active lifestyles.

Pender gave heavily to nursing organizations. She was president of the Midwest Nursing Research Society from 1985 to 1987, president of the American Academy of Nursing from 1991 to 1993, a member of Research America's Board of Directors from 1991 to 1993, and a member of the U.S. Preventative Services Task Force from 1998 to 2002. She was Associate Dean for Research at the University of Michigan School of Nursing from 1990 to 2001, and as a co-founder of the Midwest Nursing Research Society she has served as a trustee of its foundation since 2009.

Pender is a Professor Emeritus at Michigan State University. Since retiring from active teaching she advises health research nationally and internationally and serves as Distinguished Professor of Nursing at Loyola University School of Nursing in Chicago, Illinois.

Works

Pender has published widely on exercise, behavior change, and relaxation training, served on editorial boards, and edited journals and books. She is a scholar, presenter, and consultant in health promotion who has worked with nurse scientists in Japan, Korea, Mexico, Thailand, the Dominican Republic, Jamaica, England, New Zealand, and Chile. She consults to research centers and collaborates with the editor of the American Journal of Health Promotion to promote legislation supporting health-promotion research.

Selected Publications Related to Nola Pender

• Health Promotion in Nursing Practice (6th Edition)
• Pender, Nola J. Study Guide for Health Promotion in Nursing Practice
• Philosophies and Theories for Advanced Nursing Practice
• Robbins, L.B., Gretebeck, K.A., Kazanis, A.S. and Pender, Nola.J. Girls on the Move Program to Increase Physical Activity Participation, Nursing Research, 2006
• Pender, Nola.J., Bar-Or, O., Wilk, B. and Mitchell, S. Self-Efficacy and Perceived Exertion of Girls During Exercise, Nursing Research, 2002
• Eden, K.B., Orleans, C.T., Mulrow, C.D., Pender, Nola.J. and Teutsch, S.M. Does Counseling by Clinicians Improve Physical Activity? A Summary of the Evidence for the U.S. Preventive Services Task Force, Annals of Internal Medicine, 2002
• Robbins, L.B., Pender, Nola.J., Conn, V.S., Frenn, M.D., Neuberger, G.B., Nies, M.A., Topp, R.V. and Wilbur, J.E. Physical Activity Research in Nursing, Nursing School Journal, 2001

Awards and Honors of Nola Pender

Pender received the 1972 Distinguished Alumni Award from Michigan State University School of Nursing, the Midwest Nursing Research Society's Distinguished Contributions to Research Award in 1988, and an Honorary Doctorate of Science from Widener University in Chester, Pennsylvania, in 1992. The American Psychological Association gave her the Distinguished Contributions to Nursing and Psychology Award in 1997, and the University of Michigan School of Nursing named her Mae Edna Doyle Teacher of the Year the following year. She received the Midwest Nursing Research Society Lifetime Achievement Award in 2005 and was designated a Living Legend of the American Academy of Nursing in 2012.

Nola Pender's Health Promotion Model

Pender's premise: health promotion and disease prevention should come first. When prevention fails to head off problems, care in illness becomes the next priority. The model gives healthcare a path that starts upstream of disease.

What is the Health Promotion Model?

Each person carries unique characteristics and experiences that shape what they do next. The behavior-specific knowledge and affect that drive action carry strong motivational weight, and nursing can modify them. The endpoint is health-promoting behavior, which should produce improved health, better functional ability, and higher quality of life at every developmental stage. Immediate competing demands and preferences can derail those intended actions.

Pender published the model in 1982 and revised it in 1996 and 2002. It is used in nursing research, education, and practice. Built on observation and research, it puts nurses in the best position to help people improve well-being through self-care and positive health behaviors.

The model was designed as a "complementary counterpart to models of health protection." It covers behaviors that improve health and applies across the life span, helping nurses understand the major determinants of health behavior as a foundation for counseling toward well-being and healthy living.

Pender defines health as "a positive dynamic state not merely the absence of disease." Health promotion aims to raise a client's level of well-being and describes the multidimensional nature of people as they interact with the environment to pursue health.

The model works across three areas: individual characteristics and experiences, behavior-specific cognitions and affect, and behavioral outcomes.

Major Concepts of the Health Promotion Model

Health promotion is behavior motivated by the desire to increase well-being and actualize human health potential. It is an approach to wellness. Health protection, or illness prevention, is behavior motivated by the desire to actively avoid illness, detect it early, or maintain functioning within the limits of illness.

Individual characteristics and experiences cover prior related behavior and personal factors. Behavior-specific cognitions and affect cover perceived benefits of action, perceived barriers to action, perceived self-efficacy, activity-related affect, interpersonal influences, and situational influences. Behavioral outcomes cover commitment to a plan of action, immediate competing demands and preferences, and health-promoting behavior.

Subconcepts of the Health Promotion Model

Personal Factors

Personal factors are biological, psychological, and socio-cultural, and they predict a given behavior based on the nature of the target behavior. Biological factors include age, gender, body mass index, pubertal status, aerobic capacity, strength, agility, or balance. Psychological factors include self-esteem, self-motivation, personal competence, perceived health status, and definition of health. Socio-cultural factors include race, ethnicity, acculturation, education, and socioeconomic status.

Perceived Benefits of Action

Anticipated positive outcomes from the health behavior.

Perceived Barriers to Action

Anticipated, imagined, or real blocks and personal costs of a given behavior.

Perceived Self-Efficacy

The judgment of one's own capability to organize and carry out a health-promoting behavior. It shapes perceived barriers: higher efficacy lowers the perceived barriers to performing the behavior.

Activity-Related Affect

The positive or negative feeling that occurs before, during, and after the behavior, based on the behavior's own stimulus properties. It feeds perceived self-efficacy: the more positive the feeling, the greater the efficacy, and increased efficacy can generate further positive affect.

Interpersonal Influences

Cognition about the behaviors, beliefs, or attitudes of others. It includes norms (expectations of significant others), social support (instrumental and emotional encouragement), and modeling (vicarious learning by watching others). Families, peers, and healthcare providers are the primary sources.

Situational Influences

Perceptions and cognitions of a situation or context that can help or hinder behavior. They include perceived options, demand characteristics, and the aesthetic features of the setting where the health-promoting behavior is meant to happen, and they can act directly or indirectly.

Commitment to Plan of Action

The intention and identification of a planned strategy that leads to carrying out the health behavior.

Immediate Competing Demands and Preferences

Competing demands are alternative behaviors over which the individual has low control because of environmental contingencies such as work or family care. Competing preferences are alternative behaviors over which the individual has relatively high control, such as choosing ice cream or an apple for a snack.

Health-Promoting Behavior

The endpoint, an action-outcome directed at positive health: optimal well-being, personal fulfillment, and productive living.

Major Assumptions in the Health Promotion Model

Individuals actively seek to regulate their own behavior. In all their biopsychosocial complexity, they interact with the environment, transforming it and being transformed over time. Health professionals are part of the interpersonal environment that influences people across the life span. Self-initiated reconfiguration of person-environment patterns is essential to behavior change.

Propositions

• Prior behavior and inherited and acquired characteristics influence beliefs, affect, and enactment of health-promoting behavior.
• Persons commit to behaviors from which they anticipate personally valued benefits.
• Perceived barriers can constrain commitment to action and the behavior itself.
• Perceived competence or self-efficacy for a behavior increases the likelihood of commitment and actual performance.
• Greater perceived self-efficacy means fewer perceived barriers to a specific health behavior.
• Positive affect toward a behavior raises perceived self-efficacy, which can in turn raise positive affect.
• When positive emotions accompany a behavior, the probability of commitment and action rises.
• Persons are more likely to commit and act when significant others model the behavior, expect it, and provide support.
• Families, peers, and health care providers are important sources of interpersonal influence that can raise or lower commitment.
• Situational influences in the external environment can raise or lower commitment and participation.
• The greater the commitment to a specific plan, the more likely the behavior is maintained over time.
• Commitment is less likely to produce the behavior when competing demands outside the person's control demand immediate attention.
• Commitment is less likely to produce the behavior when other actions are more attractive than the target behavior.
• Persons can modify cognitions, affect, and the interpersonal and physical environment to create incentives for healthy action.

Strengths and Weaknesses

Strengths

The model is simple on the surface but structurally complex underneath. Its focus on health promotion and disease prevention sets it apart from other nursing theories, it fits the community health setting well, and it supports independent nursing practice as a primary source of health-promoting interventions and education.

Weaknesses

The model does not define the nursing metaparadigm concepts a nursing theory is expected to address: man, nursing, environment, and health. Its many concepts can confuse the reader, and it gives little emphasis to the patient currently in a disease state.

Conclusion

Because the model centers on health promotion and prevention, its relevance to caring for the already-ill patient is less clear, though that same focus is what makes it distinct. Pender opened a new way of viewing nursing care, but the curative side of practice cannot be set aside.

The community setting is the strongest place to promote health and prevent illness, and community programs can be built around the model to improve well-being. Cost is a real limit: fully adhering to a health-promoting behavior often takes financial resources, so a person who is economically unstable may commit less to the plan and reach a weaker outcome even with the will to follow through.

The model can still be applied where it is not formally stated, including the Intensive Care Unit, to improve conditions and prevent further decline. Diet modification and passive and active range-of-motion exercises are examples.