Nursing theory: Nola Pender's Health Promotion Model (HPM) In the United States and around the world, the consequences of the rise of chronic diseases like diabetes and heart disease are increasingly evident. Nola Pender's practice theory of the Health Promotion Model (HPM) was designed to offer a model of health promotion and wellness before the onset of chronic illnesses. Pender "became convinced that patients' quality of life could be improved by the prevention of problems before this occurred, and health care dollars could be saved by the promotion of healthy lifestyles" (Petiprin 2015). This practice-based theory is specifically designed to help patients help themselves and to change course in terms of their health and wellness behaviors. The model is particularly instructive to use today because of the need for more adequate self-care among patients. More and more diseases are lifestyle related thanks to the increase of calories and decrease of physical movement characteristic of the modern lifestyle. Also, limited funds necessitate that the patient engage in more self-care. Given the challenges of encouraging lifestyle changes in patients, theories such as the Pender model provide practitioners with guidance as to what proactive strategies are useful in specific instances where patients and providers must work together to foster change. The model highlights the ability of practice-based nursing theories to provide universal constructs applicable to a variety of settings, including cross-cultural ones, yet the ability of theory to simultaneously be situation-specific.

Philosophical Underpinnings of Pender's model

"Pender's theory encourages scholars to look at variables that have been shown to impact health behavior. It uses research findings from nursing, psychology, and public health into a model of health behavior" (Petiprin 2015). The nurse's role is to understand appropriate methods of intervention for the patient and to use evidence-base medicine to address what behaviors are more likely to give rise to better outcomes. Five key determinants shape the HPM just like the traditional cornerstones of nursing theory of nursing, patient, health, and environment. "The person is a biophysical organism shaped by the environment" and "the environment is described as the social, cultural, and physical context in which life unfolds" (Petiprin 2015). The nurse can work with the patient and also with communities to manipulate the environment to better enhance rather than inhibit health-promoting behaviors. For example, in many communities there is a critical lack of access to healthy food and safe places to exercise. Nurses can help patients with proactive strategies to make healthy behaviors easier. The role of the nurse extends outside of merely addressing the patient's immediate environment because no patient exists in a bubble. Thus "the role of nursing is a collaboration among patients, families, and communities to create the best conditions for the expression of optimal health and high-level well-being" (Petiprin 2015). Health is not merely the absence of illness but also the promotion of behaviors designed to support future health maintenance. "Health is defined as the actualization of human potential through goal-directed behavior, self-care, and relationships with others with necessary adjustments made to maintain relevant environments. Illnesses are discrete events in the life that can hinder or facilitate the patient's continuing quest for health" (Petiprin 2015).

Influences

Pender based her model not simply on past nursing theories but also upon other evolving theories in the social sciences, including cognitive behavioral theories which stress that changes in thought patterns help generate more positive coping mechanisms and the need for tangible behavior-oriented changes. "An individual's behaviors are driven by prior related health promotion behaviors, as well as personal factors, including biological, psychological, and sociocultural" (Syk 2008). Perceived self-efficacy is absolutely vital for change: even if the individual understands that a particular behavior will improve his or her health, changing must seem like a viable prospect and there must be a concrete plan in place to ensure such changes are implemented. "Interpersonal and situational influences on the individual" influence the possibility of change and "these perceptions and influences lead the individual to commit or not commit to a plan of action to promote health, factoring in immediate competing demands, and in turn the individual then adopts the health promoting behavior" (Syk 2008). Nurses play a critical role in helping patients envision change and create a plan. "The ability of the nurse to modify factors influencing the health-promotion behaviors of the patient lies in his or her ability to identify factors under the patient's control" (Syk 2008).

Assumptions of the Pender Model

According to Pender, the model is based upon a number of critical assumptions, specifically that "people try to create...

Pender's point-of-view thus embraces a highly optimistic view of human behavior and assumes that people innately seek out change. "People value positive growth, and strive to find a balance between stability and change" and are capable of self-regulation (Pender, cited by Petiprin 2015). Nurses assist in this self-regulation and influencing of the patient's environment, along with other relationships and interactions but fundamentally the patient is always in the driver's seat. Pender's theory stresses how the constellation of influences upon health have psychological and social elements that must be addressed in a wider context versus a purely individual basis even though it provides guidance for structuring care to promote health for specific patients.
Limitations

One potential criticism of the theory is that it does not address all states of health. Patients are still capable of self-governance, autonomy, and change to a high level. Thus while it might be applicable to a pre-diabetic adolescent seeking to enact change, Pender's theory might be less appropriate for a diabetic coming to the end of his or her life and in need of assistance for basic, daily life tasks.

Applying the HPM

Pender's theory may be applied to treating adolescent girls that are obese, overweight, or at risk for being overweight. Learning self-regulatory behavior can be extremely powerful for girls in this age group. "Development of self-regulatory capacity is associated with identity development" and there is "a relationship between these factors contributes to adolescents identifying as 'healthy eaters' or as 'exercisers' ... identity adoption and identity-congruent behavior are highly correlated, a hypothesis that has empirical support" (Todd., Street, Ziviani, Byrne, & Hills, 2015, p. 2312). Nurses can help girls identify a realistic plan for change to help them envision a new way of relating to food and their bodies. Without guidance, girls may not be able to perceive themselves as capable of change, even though according to the model ultimately it is the patient that must feel empowered in a concrete way to undertake health-related changes. Nurses can work with schools and recreational centers to ensure that exercise is available to students in a manner designed to promote regular compliance (for example, ensuring that activities in PE classes have options for all levels of students).

A study of physical activity in Taiwanese adolescents similarly supported the use of Pender's theory. "Despite the increased emphasis on the importance of physical activity" by the Taiwanese government "many Taiwanese people continue to lead sedentary life-styles. Results of recent studies show that more than 50% of Taiwanese adults age 40 or older and more than 75% of Taiwanese young people under age 20 are not physically active" (Pender & Wu, 2002, p. 26). In the HPM, it was found that perceived self-efficacy was less of a factor inhibiting changes in behavior in Taiwan but the model was still relevant given the extent to which peer behaviors and attitudes strongly influenced physical activity levels. "The strong indirect effect between interpersonal influence (social support, modeling, and norms) and physical activity also suggests that, when building successful physical activity experiences for these adolescents, health-promotion efforts should rely not only on mechanisms of verbal persuasion (norms) and emotional arousal, but also on attention to mastery and vicarious experiences (modeling), as well as providing social support for physical activity from their peers" (Pender & Wu, 2002, p. 34). This study supports the cross-cultural applicability of the Pender model for behaviors specifically related to self-efficacy such as exercise and weight loss.

View of Nursing Education

In the HPM, the nurse fundamentally takes the role of the teacher in structuring the patient's environment to promote health and providing the patient with guidance. However, just as with any other teaching relationship, the teacher learns from the student as well as the student learns from the teacher. Patients must provide input about their needs to the nurse so the nurse can determine what strategies are most effective to empower the patient and alter the patient's environment.

Conclusion

Although Pender's theory is not universally applicable to as wide a variety of nursing situations as grand nursing theory, it provides a useful theoretical construct for health empowerment. Given the need to empower patients to make healthy choices in the current age where healthcare is growing increasingly expensive even while chronic lifestyle diseases are on the rise, the HPM is more relevant than ever before.

References

Petiprin, A. (2015). Nola Pender: Nursing…