Chapter 14

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Chapter 14Chapter 14Theories From the Behavioral Theories From the Behavioral

SciencesSciences


Theories From Behavioral Sciences • The strong contribution of the behavioral or

psychological sciences to the discipline of nursing cannot be overstated.

• There are several, disparate schools of thought and foci; they can be categorized as:

– Psychodynamic theories

– Cognitive-behavioral theories

– Social-behavioral theories

– Humanistic (needs) theories

– Stress theories


Psychodynamic Theories

• Dominated psychiatry/psychology from the early 1900s

• Most widely mentioned are Freud, Erikson, Sullivan—stage theorists

• Focus on the multidimensional nature of behavior and personality


Developmental Theory—Erikson

• Erik Erikson’s psychosocial developmental theory expanded on Freud’s concept of “ego.”

• In Erikson’s theory, stages of a person’s life are formed by social influences that interact with physical/psychological, maturing individual.


Developmental Theory—Erikson—(cont.)

• Eight stages of development

– Trust vs. mistrust

– Autonomy vs. shame and doubt

– Initiative vs. guilt

– Industry vs. inferiority

– Identity vs. identify confusion

– Intimacy vs. isolation

– Generativity vs. stagnation

– Integrity vs. despair


Developmental Theory—Erikson—(cont.)• Each stage of development builds on the next, forming

the total person.

– Successful passing through the dynamics of the stage (or crisis) leads to development of virtues.

– Virtues are hope, will, purpose, competence, fidelity, love, care, and wisdom.

• The only developmental theorist who extends development through adulthood

• Erikson emphasized the adolescent stage—transition from child to adulthood.

– This period has the greatest influence on the adult personality.


Developmental Theory: Application to Nursing• Important in holistic nursing practice

• Generally associated with pediatrics, but developmental issues are important when dealing with people of all ages.

• Significant number of nursing articles deal with developmental issues:

– Life satisfaction among elderly, female, nursing home residents

– Developmental perspective on coping with cervical cancer

– Understanding how children cope with disasters


Behavioral/Cognitive-Behavioral Theories

• Behavioral theorists believe that personality consists of learned behaviors.

• Cognition was later added to focus on dynamic relationship between thinking and behavior.

• Behavioral theorists include Skinner and Beck and Ellis.


Behavioral/Cognitive-Behavioral Theories—(cont.)

• Behavioral theorists such as Skinner largely focus on stimulus–response–reinforcement premise, in which it is perceived to be possible to predict and control behaviors through use of reinforcement.

• Beck focused on changing “cognitive distortions,” which he believes contribute to individual’s misinterpreting life events.


Question

Tell whether the following statement is true or false:

Cognitive-behavior theories assert that personality is the outcome of learned behaviors—often from stimulus–response–reinforcement.


Answer

True

Rationale: Behavioral theorists believe that personality consists of learned behaviors. Behaviorists largely focus on stimulus–response–reinforcement premise, in which it is perceived to be possible to predict and control behaviors through use of reinforcement.


Behavioral/Cognitive-Behavioral Theories—(cont.)

• Most commonly used in nursing and health care in helping people change detrimental behaviors (i.e., stop smoking) and manage mental illness. Examples:

– Therapeutic use of cognitive-behavioral therapy for clients with dual diagnoses

– Behavioral techniques used to promote toileting among impaired elders

– Cognitive-behavioral counseling for infertile women

– Use of cognitive-behavioral strategies to promote health


Humanistic Theories

• Developed in response to psychoanalytic theories that didn’t consider potential or capacity for self-actualization

• Most well known of the humanistic theories is the work of Abraham Maslow.


Maslow’s Hierarchy of Needs

• Motivation is key to Maslow’s theory.

– Believed that individuals strive for self-actualization

• There are several incremental states of Maslow’s theory (physiologic, safety, love and belonging, self-esteem, knowledge and understanding, esthetic needs, and self-actualization and transcendence).

• The goal is to attain the last level—self-transcendence.


Maslow’s Hierarchy of Needs—(cont.)

• Each individual must meet the “deficiency” needs—those that are essential for survival—before meeting higher level needs.


Maslow’s Hierarchy of Needs and Nursing

• Many nursing articles use Maslow as a framework for research or to discuss meeting the needs of patients in practice. For example:

– One study examined the love and belonging needs of HIV+ African American men.

– A study looked at unmet basic needs of clients in an ED.

– One study examined job satisfaction (self-esteem and actualization) among nurses.

– An article looked at quality of life in transplant patients using Maslow’s work.


Social Psychology Theories—Focus on Health Behaviors

• Social psychology theories include models for understanding behavior change.

• When health providers try to encourage healthy behaviors, they are competing against powerful influences.


Social Psychology Theories—Focus on Health Behaviors—(cont.)

• Social psychology theories that focus on health behaviors are among the most frequently used non-nursing theories in nursing research.

• The most frequently cited are the Health Belief Model and the Theory of Planned Behavior (Reasoned Action).


Health Belief Model

• The Health Belief Model (HBM) focuses on a person’s perceptions of a threat or a health problem and related appraisal of a recommended behavior to elicit change.

• The HBM was developed in the 1950s and was one of the first models using concepts and assumptions from behavioral sciences to examine health behaviors.

– Addresses attitudes and beliefs of individuals

– Focus was on increasing the use of preventive health services.


Health Belief Model—(cont.)

• Primary assumptions of the model are that people fear disease and that health actions are motivated based on the extent of the fear and belief in benefits obtained by preventative action.

• Five primary constructs

– Perceived susceptibility

– Perceived severity

– Perceived benefits

– Perceived barriers to action

– Cues to action


The health belief model. (From Becker, M. H., Haefner, D. P., Kasl, S. V., et al. [1977]. Selected psychosocial models and correlates of individual health-related behaviors. Medical Care, 15, 27–46, with permission.)


Question

Which of the following is NOT a construct of the Health Belief Model?

A.Perceived barriers

B.Perceived benefits

C.Perceived control

D.Perceived severity


Answer

C. Perceived control

Rationale: According to the Health Belief Model, health actions are motivated based on the extent of the fear and belief in benefits of action. The primary constructs are perceived susceptibility, perceived severity, perceived benefits, perceived barriers to action, and cues to action.


Health Belief Model—(cont.)• The HBM has been used extensively by nurses as a

framework for research projects.

• There were 140 citations of its use in nursing literature over the last decade.

• Examples

– Using message intervention (cue to action) to prevent readmission among heart patients

– Explanation of women’s use of HRT

– Study of compliance with universal precautions among OR nurses

– Prevention of STDs among adolescents


Health Belief Model—Resources

• For more information:

http://www.utwente.nl/cw/theorieenoverzicht/theory%20clusters/health%20communication/health_belief_model.doc/

http://changingminds.org/explanations/belief/health_belief_model.htm

http://www.utwente.nl/cw/theorieenoverzicht/theory%20clusters/health%20communication/health_belief_model.doc/

http://changingminds.org/explanations/belief/health_belief_model.htm


Theory of Planned Behavior (Ajzen & Fishbein)

• The Theory of Planned Behavior (initially called the Theory of Reasoned Action) was proposed in 1967 and revised in 1980.

• The theory assumes that people make rational decisions based on the information available to them.


Theory of Planned Behavior (Ajzen & Fishbein)—(cont.)

• Intent is a central concept of the model and a primary determinant of behavior; intentions depend on three factors.

– Attitude—the individual’s belief that behaviors lead to certain results and his/her positive or negative evaluation of performing the behavior

– Subjective norms—the social pressure to perform or not perform a behavior

– Perceived control—the individual’s belief he/she has the ability, knowledge, resources, etc. to perform the behavior


Question

In the Theory of Planned Behavior, intention is based on subjective norms, perceived control, and:

A.Attitude

B.Health knowledge

C.Motivation

D.Perceived value of action


Answer

A. Attitude

Rationale: In the Theory of Planned Behavior, attitude is seen as the individual’s belief that behaviors lead to certain results and are determined positive or negative evaluation of performing the behavior. In general, the more favorable the attitude and the subjective norm, and the greater the perceived control, the stronger the person’s intention to perform the behavior in question.


Theory of reasoned action and theory of planned behavior. (From Ajzen, I., & Fishbein, M. [1980, p. 8]. Understanding attitudes and predicting social behavior. Reproduced by permission of Pearson Education, Inc. Upper Saddle

River, NJ.) The lighter-shaded upper section shows the theory of reasoned action; the entire figure shows the theory of planned behavior.


Theory of Planned Behavior and Nursing

• The Theory of Planned Behavior is widely used in nursing research.

• There are 75 articles in the last decade published in nursing literature; most were research. Examples:

– Medication taking beliefs of renal transplant patients

– Elderly women’s beliefs related to exercise

– Health care workers adherence to hand hygiene recommendations

– Exercise among blue collar workers

– Predictors of sexual intercourse and condom use among youth


Theory of Planned Behavior—Example

For more information:

http://www.utwente.nl/cw/theorieenoverzicht/Theory%20clusters/Health%20Communication/theory_planned_behavior.doc/


Stress Theories

• Stress, adaptation, and coping are concepts frequently found in nursing literature, and related theories can be found in both the psychology literature and physiology.

• Stress is inevitable, and people must deal with stress by adapting though coping.


Stress Theories—(cont.)

• Stress theories allow us to understand the effects that stress has on the individual and how the individual responds to stressful situations and life events.

• Two theories commonly used in nursing:

– Selye’s general adaptation syndrome

– Lazarus’ Stress and Coping Adaptation Theory


General Adaptation Syndrome

• Hans Selye pioneered research into stress and proposed the general adaptation syndrome in the 1960s.

– Focused on physiologic response to stress

– Theories derived from observations of people who were ill

– General adaptation syndrome to recognize general changes to the body


General Adaptation Syndrome—Three Stages• Stage 1—alarm phase

– Begins with fight-or-flight response

– CNS responds

– Adrenal glands release hormones

– Increases blood glucose and depresses the immune system


General Adaptation Syndrome—Three Stages—(cont.)

• Stage 1—alarm phase—(cont.)

– Increased heart rate, increased perspiration, dilation of pupils

– Individual experiences increased alertness and awareness.

– If stage is prolonged, detrimental changes (e.g., gastric problems) occur.


General Adaptation Syndrome—Three Stages—(cont.)• Stage 2—resistance stage

– If the threat/stress continues

• Physiologic forces adapt to maintain increased resistance.

• ACTH decreases and the body concentrates on organs that are involved in stress responses.

• Adaptation implies return or improvement in health.


General Adaptation Syndrome—Three Stages—(cont.)

• Stage 2—resistance stage—(cont.)

– If the threat/stress continues

• Ineffective resistance leads to maladaptation.

• May feel threatened, overloaded, and depressed

• May experience psychosomatic symptoms

– If threat/stress ends

• Body returns to homeostasis

– Chronic resistance eventually causes damage to the involved systems.


General Adaptation Syndrome—Three Stages —(cont.)

• Stage 3—exhaustion stage

– Occurs when the stressor persists and the body cannot continue to produce hormones as in stage 1 or when damage has occurred

– Symptoms include hypertrophy of the adrenal glands, ulceration in the GI tract, and atrophy of the thymus gland.

– Individual may feel helpless and loss of control.


General Adaptation Syndrome and Nursing

• Several of the grand nursing theories cite Selye’s GAS as one of the theories their works was drawn. These are:

– Dorothy Johnson

– Betty Neuman

– Erickson, Tomlin, and Swain

– Callista Roy


General Adaptation Syndrome and Nursing—(cont.) • Several middle range theories have also been developed

based on GAS or RAM. These include:

– A theory of psychological adaptation derived from the RAM (Levesque et al., 1998)

– A theory of stress and stress response based on concepts from GAS (Motzer & Hertig, 2004)

– A theory of chronic pain based on the RAM (Tsai et al., 2003)

– A theory of caregiver stress based on the RAM (Tsai, 2003)


Transactional Model of Stress and Coping (Lazarus; Lazarus & Folkman)

• The Transactional Model focuses on psychological responses of coping with stressful events.

• Two major factors that contribute to stress

– Person–environment relationship (transactions)

– Appraisals


Transactional Model of Stress and Coping (Lazarus; Lazarus & Folkman)—(cont.)

• Person–environment relationship includes such factors as personality, values, beliefs, social networks, social support, life events, and cultural factors.

• Three types of appraisals

– Primary appraisal—judgment an individual makes about an event or stressor

– Secondary appraisal—evaluation of how an individual responds to an event

– Reappraisal—appraisal after new or additional information has been received



• Coping relates to how a person perceives a threat.

• Coping occurs to manage demands and emotions generated by appraised stress.

• Two types of coping

– Problem-focused coping

– Emotion-focused coping



• Among the most frequently used non-nursing theories in nursing

– Neuman, Erikson, Tomlin, & Swain, and Roy noted using Lazarus’ work in developing their theories.

• During the last decade, 139 articles were published in the nursing literature using the model. Examples include:

– Stress and coping strategies in older women with arthritis

– Stress and coping in high-risk mothers

– Coping among adolescents with epilepsy

– Coping and stress in parents with infants in the NICU

Chapter 14

Technology

developmental issues

developmental theorist

discipline of nursing

development of virtues

eriksons theory

sullivanstage theorists

holistic nursing practice

stages of development