Kristi - To begin, click the "edit" tab in the upper right corner. I copied the paper outline below so we can make sure all points have been addressed. Happy wiki-ing!

For many, the journey into nursing began when the nurse or a family member fell ill. This experience gave the nurse one of his or her first views into healthcare and the duties performed by the nursing staff. The same is true for nurse theorist Nola J. Pender. At the age of 7, Pender’s aunt was hospitalized. She states, “The experience of watching the nurses caring for my aunt in her illness created in me a fascination with the work of nursing,” (Alligood & Tomey, 2010). And so began Pender’s journey into nursing and consequent formation of her Health Promotion Model.

According to an interview given by Pender (Fitne, Inc, 2008), she wanted to develop a theory focusing on a positive health seeking behavior approach rather than the negative approach she had seen used in other theories. Her concepts help identify influences in the patient’s perceptions and cognitions that the nurse needs to address in order for the patient to be able to adopt positive lifestyle behaviors. Pender’s educational experience also helped to shape her middle-range theory. She earned her PhD. in psychology and education, so her assumptions and concepts come from a behavioral science viewpoint.

Alligood and Tomey (2010) list the assumptions of the Health Promotion Model in this way: 1) Persons seek to create conditions of living through which they can express their unique human health 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) Individuals seek to actively regulate their own behavior. 5) Individuals in all their biopsychosocial complexity interact with the environment, progressively transforming the environment and being transformed over time. 6) Health professionals constitute a part of the interpersonal environment, which exerts influence on persons throughout their life spans. 7) Self-initiated reconfiguration of person-environment interactive patterns is essential to behavior change (pp. 441). Again, Pender’s desire to focus on positive aspects can be seen in her assumptions. She assumes that patients value positive change and that they are capable of self-awareness and self-assessment. In evaluating these assumptions, one must implicitly assume that the patient has the mental and physical capacities to actively decide on their health behaviors. Severe mental disabilities or injury may prevent the patient, who wants to participate in healthy behaviors, from doing so.

In addition to developing theoretical assumptions, the nurse theorist must also develop the concepts of his or her theory. Concepts are formulated for both the large scale nursing metaparadigm and also for the specific theory. Pender defines the metaparadigm concept of person as a biopsychosocial entity that is shaped by the environment, but who also seeks to create its own environment where it can express its full potential. Its relationship with the environment is reciprocal. The environment is the context, whether that be social, cultural, or physical, in which the life course takes place. It can be altered so that the person may be able to more readily participate in health promoting behaviors. Health is defined as the person realizing inherent and acquired potential through their goal directed behavior in the areas of self-care, social relationships, and body integrity. Finally, nursing is defined by Pender as working in partnership with the patients, their families, and communities to create a positive and supporting environment in which the patient can express their full potential and perform health promoting behaviors (N. Pender, personal communication, September 14, 2011).

Pender’s theory is based on the concepts of prior related behavior, personal factors, including biological, psychological, and sociocultural factors, perceived benefits of actions, perceived barriers to action, perceived self-efficacy, activity-related affect, interpersonal influences, situational influences, intention, immediate competing demands and preferences, and health-promoting behavior.

According to Alligood and Tomey (2010), prior related behavior is defined as how often the patient has displayed a specific, or similar, health promoting behavior in the past. It can be directly or indirectly linked to the likelihood they will engage in this behavior again. Personal factors, separated into the subgroups of biological (age, gender, body mass index, pubertal status, menopausal status, aerobic capacity, strength, agility, and balance), psychological (self-esteem, self-motivation, personal competence, perceived health status, and definition of health), or sociocultural (race, ethnicity, acculturation, education, and socioeconomic status) are seen as predictive indicators of a given behavior. Perceived benefits of action are the positive outcomes the patient believes will happen as a result of healthy behavior, while perceived barriers to action are the real or imagined block and personal cost of performing a health behavior. Perceived self-efficacy is the patient’s judgment of their own ability to carry out a health behavior. Activity-related affect is how the patient feels before, during, and after a health behavior. The stimulus of the behavior may cause positive or negative feelings. Interpersonal influences are defined as “cognitions concerning behaviors, beliefs, or attitudes of others.” This may include norms, social support, and role modeling of others. Situational influences are the thoughts and perceptions regarding a certain situation or context in which the behavior is occurring. These perceptions may enhance or encumber the behavior. Intention is a commitment to a strategy or plan of action once it has been developed. Competing demands and preferences are alternative choices of behaviors that the patient has low or high control over, respectively. Finally, a health promoting behavior is defined as an end point that moves the patient toward the goal of achieving positive health outcome.

As one continues to study Pender’s Health Promotion Model, a circular pattern of conceptual relationships begin to appear. As one concept is influenced either positively
or negatively, it begins a domino effect that alters the following concepts. For example, activity-related affect is directly related to self-efficacy. A positive affect will increase self-efficacy, whereas a negative affect will decrease self-efficacy. From there, perceived self-efficacy is inversely related to perceived barriers to action. As the patient’s self-efficacy increases, the number of barriers decreases. As perceived barriers to action decrease, the commitment to perform a health action increases. This cause and effect configuration continues through most of the concepts (Figure 1).

(Here I drew my own figure, but it won't paste in a wiki. It's a pretty simple circular diagram with arrows pointing in a clock-wise direction)

The remaining concepts not pictured in Figure 1 act as modifiers. These include the concepts of prior related behavior, personal factors, interpersonal influences, situational influences, and immediate competing demands and preferences. For example, if the patient’s family (interpersonal influence) is supportive and enabling of a health behavior, this will increase commitment to action. Another example may be if the patient has too many competing demands such as work, school, or family obligations. This will increase perceived barriers and have a negative effect on the conceptual relationships.

Pender’s theoretical assertions, or propositional statements, about the Health Promotion Model mimic the conceptual relationships. She has listed 14 statements regarding the biopsychosocial interactions of a person with their environment that can affect health promoting behaviors: 1) Prior behavior and inherited and acquired characteristics influence 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 the commitment to action, the mediator of behavior, and the 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 specific health behavior. 6) Positive affect toward a behavior results in greater perceived self-efficacy, which, in turn, can result in increased positive affect. 7) When positive emotions or affect is associated with a behavior, the probability of commitment and action is 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) Families, peers, and healthcare providers are important sources of interpersonal influences that 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 are to 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 (Alligood & Tomey, 2010, pp 441-442). These statements can be used to formulate hypotheses for nursing research and to develop instruments for research such as the Health Promoting Lifestyle Profile and the Exercise Benefits-Barriers Scale (Alligood & Tomey, 2010).

Nola Pender's Health Promotion Model is considered a middle range theory. Middle range theories, are considered more operationalized and more thoroughly evaluated through research than grand theories. The function of a middle range theory is to describe, explain, or predict phenomena, and must be explicit and testable in order that they may be able to be applied to practice situations and as a framework for research studies. (McEwen and Wills, 2007).

Pender's Health Promotion Model is a middle range nursing theory derived from a behavior theory understood as a social learning theory and expectancy-value theory. Pender's HPM, proposed as a framework for integrating nursing and behavioral science perspectives on factors influencing health behaviors, is to be used as a guide to explore the biopsychosocial processes motivating individuals to engage in behaviors directed toward health enhancement (Pender, 1996). This model has been used extensively as the basis for research guided toward predicting health promoting lifestyles along with specific behaviors. A CINAHL search conducted in late 2004 produced listings for 148 English language articles reporting using or applying Pender's HPM during the last ten years. While some studies have used Pender's work as one component of a conceptual framework for their study, others use health promotion as an outcome, and still others have used the HPM to predict behaviors (McEwen & Wills, 2007).

As with many middle range theories, Pender used available research studies to inductively develop her conceptual model. She pieced together findings from previous research and developed a model that cohesively helps to explain and predict the occurrence of health promoting behaviors. This model also gives way to further research and testing into the area of health promotion (Alligood & Tomey, 2010).

Pender's concepts and the relationships between them are easy to understand. It is reasonable to believe that people wish to be in a state of optimal well-being and independence. The relationships between concepts are also logical. When one is provided with the needed support and obstacles are removed, the likelihood of goal attainment is increased. Pender's definitions of concepts and their relationships remain consistent throughout the use of her theory.

The Health Promotion Model has been tested with patient populations across the lifespan including adolescents, working adults, and older adults in the community. Its ability to be used with a vast array of patient groups in numerous setttings has made it well liked in the nursing community. As the focus of nursing shifts from disease management to disease prevention/health promotion, Pender's model proves to be very useful and relevant (Alligood & Tomey, 2010). The simplicity of this model, with only 10 easy-to-understand concepts, is also seen as a positive. The circular relationship of the concepts (see Figure 1) is easy to follow and logical in its progression. The concepts are abstract enough that it can be applied to many situations, yet not so abstract that the nurse following the model is lost and has difficulty applying it to his or her own practice. The nurse caring for the well patient can use this model to continue to keep the patient in a state of optimal health. The nurse caring for the sick patient may use this model to move that patient towards an increased state of health and wellness. However, this model is focused on particular individuals and is not easily generalizable to groups or community populations.

The Health Promotion Model is widely used by researchers. Frenn et al. (2003) studied nutrition and exercise in middle school students, devised a plan for educating these students on improving their health and diet, and wrote about it in their article, "Addressing Health Disparities in Middle School Students' Nutrition and Exercise." The study was based on the Transtheoretical and Health Promotions Models, and was tailored to participants stage of change.

Each participant was placed in a category reflecting their desire to change their health and exercise behaviors, and education was tailored to their stage of change. A four-session internet and video intervention, along with a gym lab and online feedback, was tested in two middle schools during the 2000-2001 academic year, and improvement was evaluated using the Healthy People 2010 Objectives.

When measuring the outcome of the study, the importance of making the change in behavior, described as benefits-barriers ratio in the Health Promotion Model, was reported separately. Participants who had easier access to low-fat, high-quality foods, along with access to exercise programs and facilities, a Health Promotion construct, scored higher on each instrument (Fenn et al., 2003). The Health Promotion Model suggests nursing education must also take into better consideration cultural and situational factors that affect health promotion. For example, it is not enough to merely say 'eat better' and suggest eating more low-calorie foods to a participant. A participant's palate, derived from their cultural background, level of income, and daily routine should be taken into consideration when recommending changes.

The results of the study showed effectiveness in the intervention by an increase in fat reduction with each internet session attended to by the participants, and an increase in moderate and vigorous physical activity for those participating in the peer-led physical activity lab. Using aspects of the Health Promotion Model, Frenn et al. (2003) developed an evidence based educational program for middle school aged children constructed on their research study to improve nutrition and exercise, especially among girls who are at a greater risk of obesity in later life.

Educators Daggett and Rigdon (2006) developed an education program for combating obesity and wrote an article entitled, "A Computer-Assisted Instructional Program for Teaching Portion Size Versus Serving Size." Using Pender's Health Promotion Model as the theoretical framework, Daggett and Rigdon (2006) successfully developed an easy to understand computer assisted informational DVD with take home booklets. A community medical center implemented the program as part of a nutrition-based weight management course.

The Health Promotion Model emphasizes people interacting with their personal and physical environments as they strive for optimal health. (Pender, Murdaugh, &Parsons, 2002). Education projects, such as the one developed by Daggett and Rigdon (2006), can easily use this framework as it is an appropriate guide for examination of the biopsychosocial processes prompting participants to engage in behavior which will ultimately result in the improvement of their health. (Dagget & Rigdon, 2006).

Pender developed her model to be easily accessible and useable in nursing practice. Ho, Berggren, and Dahlborg-Lyckhage (2010), addressed diabetes self-care management and the need for health care workers to facilitate empowering behaviors to diabetic clients in their article, "Diabetes empowerment related to Pender's Health Promotion Model: A meta-synthesis."

In the Health Promotion Model, nurses can play a pivotal role in helping patients "shape a positive behavioral history for the future by focusing on the benefits of a behavior, teaching clients how to overcome hurdles to carrying out the behavior, and engendering high levels of efficacy and positive affect through successful performance experience and positive feedback" (Pender et al., 2006)

Ho, Berggren, and Dahlborg-Lyckhage (2010) concluded that addressing modifiable behavior-specific variables in the Health Promotion Model will help health-care professionals to assist clients in overcoming barriers and enhancing self-efficacy in relation to lifestyle modification. Implications for practice included assessing clients' total life situation, using the Health Promotion Model as a guide to aid clients' self-efficacy, along with bolstering the cultural competency of health-care providers (Ho, Berggren, & Dahlborg-Lyckhage, 2010).

The Health Promotion Model is applicable to any practice setting. In my own current practice within an acute care setting in the Emergency Room, I use the Health Promotion Model on an everyday basis. After the acute phase of an emergency has passed, patients are often approachable to education about modifiable behaviors. While there is not time for lengthy conversations, short quick teachings can make an enormous difference. For example, a patient with an acute asthma exacerbation, once able to breathe, will be given a nebulizer and taught how to use it if they do not have one at home. We will also discuss health promoting behaviors for patients who have had bicycle accidents on the use of safety helmets. One of my pet projects is healthy baby and breastfeeding initiatives. Any time a pregnant client is in the emergency department, I will discuss healthy eating during pregnancy and try to make certain the patient has access to OB care. Our emergency department also has referrals for sliding scale clinics, dental clinics, diabetes management, and help for medication purchasing. We attempt to make certain each client receives the aid they need in getting continued follow up health care so that they do not use the emergency room for inappropriate visits. Our staff attempt to teach clients that the emergency room is not a substitute for regular health care, so that they will follow up with the care they need.











  1. Description of the theory including assumptions, conceptual definitions and propositional statements. Content below provides the format you follow in analyzing and evaluating the theory:
  2. Internal evaluation and analysis of the theory
    1. Evaluate assumptions, both explicit and implicit. Assumptions are statements that are understood to be true without proof or demonstration. They are beliefs about phenomena one accepts as true.
    2. How does the theorist define the four concepts of the paradigm of nursing? These concepts are: Nursing, Environment, Person and Health. Most theorists have defined these concepts differently.
    3. How does the theorist define and inter-relate major concepts of their own theory?
    4. Evaluate propositional statements
    5. Analyze consistency of the theory. Consistency (logical form) refers to systematic development and structural clarity. Definitions of concepts should be consistent across the theory and relationships across concepts clearly identified. Is the theory logical?
    6. Comment on the adequacy, simplicity and generality of the theory. Adequacy is a term that refers to how the theory is accepted by the nursing community. Is it applicable to practice? Does this theory explain nursing? Simplicity refers to having few concepts and simple relationships. Complex theory would have many concepts and multiple relationships. Generality refers to the scope of concepts and goals. The more limited the concepts and goals, the less general the theory. The more general the theory, the greater the applications.
    7. Type of theory refers to: Grand theory, Middle range or Micro theory, Philosophy.
  3. External evaluation and analysis
    1. Relationship of theory to practice (summarize an article)
    2. Relationship of theory to education (summarize an article)
    3. Relationship of theory to research (summarize an article)
    4. Draw conclusions about how applicable this theory is to nursing practice, research and education.
    5. How can you apply the theory in your own current practice setting?

According to an interview given by Pender (Fitne, Inc, 2008), she wanted to develop a theory focusing on a positive health seeking behavior approach rather than the negative approach she had seen used in other theories. Her concepts help identify influences in the patient’s perceptions and cognitions that the nurse needs to address in order for the patient to be able to adopt positive lifestyle behaviors. Pender’s educational experience also helped to shape her theory. She earned her PhD. in psychology and education, so her assumptions and concepts come from a behavioral science viewpoint.
Alligood and Tomey (2010) list the assumptions of the Health Promotion Model in this way: 1) Persons seek to create conditions of living through which they can express their unique human health 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) Individuals seek to actively regulate their own behavior. 5) Individuals in all their biopsychosocial complexity interact with the environment, progressively transforming the environment and being transformed over time. 6) Health professionals constitute a part of the interpersonal environment, which exerts influence on persons throughout their life spans. 7) Self-initiated reconfiguration of person-environment interactive patterns is essential to behavior change (pp. 441). Again, Pender’s desire to focus on positive aspects can be seen in her assumptions. She assumes that patients value positive change and that they are capable of self-awareness and self-assessment.