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Literature Critique of Advanced Nursing Role Theories Supporting Health Promotion
Overview
As the profession of the Advanced Practice Registered Nurse (APRN) continues to evolve within the healthcare system, the utilization of theory-guided practice is imperative for the deliverance of purposeful and effective care to patients. The use of theory in nursing gives APRNs the ability to organize and structuralize knowledge to guide patient care (McEwen & Wills, 2019). Multiple nursing theories exist dating back to Florence Nightingale. A thorough examination of the literature revealed two theories of particular importance to an APRNs role in health promotion and disease prevention. Nola J. Penders Health Promotion Model (HPM) and Icek Ajzens Theory of Planned Behavior (TPB) both focus on the factors influencing human behavior (Pender, 2011; Ajzen, 1991). Underpinning knowledge of these theories can benefit APRNs in practice by providing frameworks that facilitate recognition, comprehension, and modification of health behaviors.
Nola J. Pender is a nursing theorist that published the Health Promotion Model in 1982, which has since been revised in 2011 (Pender, 2011). The purpose of the HPM is to provide nurses with a framework to identify the determinants of patient behavior and influence health-promoting interventions (Pender, 2011). The model is based on the assumption that individuals can regulate their behaviors but are influenced by numerous personal and environmental factors (Pender, 2011). Behavioral specific cognitions such as perceived benefits, barriers, self-efficacy, activity-related affects, interpersonal influences, and situational influences can be assessed and modified (Pender, 2011). With the use of the HPM, APRNs can positively influence behavioral modification changes with counseling and education.
Icek Ajzens Theory of Planned Behavior was originally published in 1985 as an extension of the Theory of Reasoned Action (Ajzen, 1991). Although not identified as a nursing-specific theory, a substantial amount of nursing research has utilized the TPB as it relates to healthcare. The TPB proposes an individuals intentions can be predicted through attitudes, subjective norms, and behavioral control to produce specific behaviors (Ajzen, 1991). An intention can be further described as the individuals motivating factors. Ajzen proclaimed an understanding of an individuals intentions and ability can support behavioral modification changes (Ajzen, 1991). Self-reflection of ones personal beliefs, readiness, and willingness for change are the ultimate factors affecting the ability to control behavior. APRNs can utilize this theory in practice to identify unhealthy behaviors and support self-reflection.
Application of Theory
The Family Nurse Practitioner (FNP) plays a specific role in providing primary advanced nursing care to all age groups and promoting public health within the community. Continual health promotion and disease prevention is an essential role for FNPs working in any specialty. The ultimate health care goal is to improve the overall quality of life (Thomas et al., 2014). The use of both Pender and Ajzens theories in practice can assist FNPs in identifying the determinants for patient nonadherence to treatment regimens, poor health behaviors, and provide patient awareness of healthy versus unhealthy behaviors. The application of these theories can be used with every patient/family interaction from the pediatric population to the geriatric population. Family Nurse Practitioners can use theory-guided practice to promote health during the patient interview, goal setting, counseling, and follow-up visits (Thomas et al., 2014). Not only is provider awareness of patient behaviors imperative for developing a patient-specific plan of care, but also patient awareness of self-care, health behaviors, and willingness is significant for patients to accomplish and sustain long term goals. Utilization of these frameworks can provide patients with self-awareness of factors influencing their lifestyle choices. FNPs can then educate patients on the appropriate individualized lifestyle changes that are needed while working with the patient to set and evaluate goals. Therefore, the ultimate goal of implementing health-promoting behaviors to facilitate an overall improved quality of life can be met.
A multitude of research has been conducted using these theories as the theoretical framework to explain and alter situations such as smoking cessation, weight loss, patient safety, adherence with chronic illness, nutritional behaviors, HIV prevention and behaviors, diabetes self-management, breastfeeding duration, generalized health-promoting behaviors in everyday life, and much more (Thomas et al., 2014; Rich et al., 2015; Khodaveisi et al., 2017; Khani et al., 2020; Lee et al., 2017; Lau et al., 2018). For example, diabetic control relies on a treatment regimen consisting of lifestyle modifications and pharmacological treatment. Lee et al. (2017) suggests the use of the TPB to assess the patients personal beliefs, intentions, and expectations for diabetic self-management; identify healthy interpersonal and situational influences; and improve patient perception of behavioral control to meet long-term goals in diabetes management. FNPs can assess patient intentions related to maintaining a healthy diet, physical activity, weight reduction, and administration of medications. If the patient identifies a negative factor preventing appropriate diabetic self-management such as the affordability of healthy foods, FNPs can provide the patient with the appropriate resources to maintain a healthy diet (Lee et al., 2017). Following the theoretical frameworks in practice can, therefore, enhance adherence to the plan of care.
Theory Importance in Healthcare Practice
Often providers are caught up in the fast-paced nature of healthcare. A quick assessment of the patients condition followed by the diagnosis and treatment requirements cause patients to have low self-efficacy, poor motivation, and lack of self-control over their health. Providers expect the patient to adhere to suggestions before the patients health behaviors have been assessed appropriately. Ultimately, this leads to an increase in preventable illness, poor chronic condition management, and unhealthy behaviors.
Through my personal reflection, many examples utilizing these theories and lack thereof come to mind. When caring for pediatric patients, the parents are in control of the childs fundamental health status. One example using the HPM in practice reflects a parents refusal of immunizations for their newborn infant. Working in a newborn nursery, it is common practice to obtain consent for the Hepatitis B vaccination at birth. The parents have the right to consent or refuse, however, providers strongly recommend and advocate for vaccination. During this time, we often learn of the parents intent to refuse all childhood vaccinations.
In this particular case, the parents of a newborn had been asked if they would like for their child to be immunized with the first dose of the Hepatitis B vaccine. They were provided with appropriate educational materials and verbally explained the importance of vaccination to obtain immunity and prevent unwanted illness. The parents refused without explanation and disclosed their intent to refuse all childhood immunizations. This being within the parents rights, the refusal papers were signed. Later when the newborn and parents were in the nursery, the Pediatric Nurse Practitioner (PNP) asked the parents why they refused the Hepatitis B vaccine. The parents once again disclosed their intent to not vaccinate their child. Instead of accepting their response, the PNP started asking about their beliefs, attitudes, and expectations of their childs health. The parents stated that their families had strongly recommended against vaccination because of the potential for autism. The parents also expressed the belief that contracting these preventable childhood illnesses would provide future immunity and make their childs immune system stronger. The final concern was of the parents financial status and the potential inability to maintain child wellness visits. The PNP intently listened to all of the parents concerns. He then asked the parents if they, themselves, had been vaccinated as children in which they had. By interviewing the parents, the PNP determined the negative factors influencing the health behavior decisions for their child as the lack of family support, personal beliefs related to the benefits and consequences of vaccination or lack of, and financial ability.
The PNP went on to educate the parents on the benefits and necessity of the immunization to prevent disease. He discussed and provided materials explaining the disease process, symptoms, and treatments of Hepatitis B and multiple other vaccine-preventable diseases. The next day, the PNP asked the parents if he could include the family members in the discussion of vaccine importance. The parents agreed and the PNP repeated immunization counseling to the entire family. Furthermore, the PNP called case management and was able to have the newborn placed on TennCare. By assessing the factors influencing their behaviors, the PNP was able to eliminate the concerns swaying the parents decision. Together, the PNP and the parents developed a plan to maintain child well visits and obtain vaccinations. By having an understanding of the HPM, the PNP followed the step by step approach to achieve health-promoting behaviors for the childs well-being.
Conclusion
In conclusion, the application of Pender and Ajzens theories promote the recognition, comprehension, and modification of healthy behaviors. Theory-guided practice provides APRNs of any specialty with the appropriate framework to individualize the plan of care needed for health promotion and disease prevention. With an underpinning knowledge of theories useful to the APRN role, APRNs can provide care that is likely to achieve better outcomes and meet long-term goals.
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