DQ: Middle-range theory or grand theory


DQ: Middle-range theory or grand theory

DQ: Middle-range theory or grand theory

Choose a middle-range theory or grand theory that, in your opinion, can be applied to practice. What are the assumptions underpinning this theory? Discuss how this theory finds application in your area of practice

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This week introduced you to grand theories and middle-range theories that serve to articulate the voice of nursing within healthcare.

Here are the key points covered:

Grand theories are comparatively more abstract than middle-range theories since they are at a higher level of abstraction. Compared to grand theories, middle-range theories are made up of limited number of concepts that lend themselves to empirical testing. All theories help to explain human health behavior.

· Sister Callista Royï’s adaptive model theory is built on the conceptual foundation of adaptation. It identifies the positive role that nursing plays in the promotion and enhancement of client adaptation to environments that facilitate the healing process. DQ: Middle-range theory or grand theory

· Leiningerï’s culture care theory is pertinent in the current multicultural healthcare environment where nurses are exposed to diverse cultures.

· Penderï’s health promotion and disease prevention theory can be called as a “direction setting exercise” for nursing professionals. It believes in fostering the spirit of health promotion and disease and risk reduction.

From the chapter, Models and Theories Focused on Nursing Goals and Functions, read the following: The Health Promotion Model: Nola J. Pender

From the chapter, Models and Theories Focused on a Systems Approach, read the following:

The Roy Adaptation Model

From the chapter, Models and Theories Focused on Culture, read the following:

Leininger’s Cultural Care Diversity and Universality Theory and Model

SO, THAT IS WHY I ASSUMED THAT HAS TO BE ONE OF THEM (Pender, Roy Adaptaion or Leininger)


Week 4 Chapter 17

Models and Theories Focused on Nursing Goals and Functions

The Health Promotion Model: Nola J. Pender


Nola J. Pender was born in 1941 in Lansing, Michigan. She graduated in 1962 with a diploma in nursing. In 1964, Pender completed a bachelor’s of science in nursing at Michigan State University. By 1969, she had completed a doctor of philosophy in psychology and education. During this time in her career, Pender began looking at health and nursing in a broad way, including defining the goal of nursing care as optimal health.

In 1975, Pender published a model for preventive health behavior; her health promotion model first appeared in the first edition of the text Health Promotion in Nursing Practice in 1982. Pender’s health promotion model has its foundation in Albert Bandura’s (1977) social learning theory (which postulates that cognitive processes affect behavior change) and is influenced by Fishbein’s (1967) theory of reasoned action (which asserts that personal attitudes and social norms affect behavior).

Pender’s Health Promotion Model

McCullagh (2009) labeled Pender’s health promotion model as a middle-range integrative theory, and rightly so. Fawcett (2005) decisively presented the difference between a conceptual model for nursing and a model for middle-range theory. A model for middle-range theory is usually a graphic representation or schematic diagram of a middle-range theory. McCullagh’s (2009) rationale for labeling Pender’s model a middle-range integrative theory is that it portrays the multidimensionality of persons interacting with their interpersonal and physical environments as they pursue health while integrating constructs from expectancy-value theory and social cognitive theory with a nursing perspective of holistic human functioning (Pender, 1996). With the third edition of Health Promotion in Nursing Practice (1996), Pender revised the health promotion model significantly. This revised model is the subject of the discussion in this chapter.

Pender’s health promotion model includes three major categories: (1) individual characteristics and experiences, (2) behavior-specific cognitions and affect, and (3) behavioral outcome. Each of these categories will be considered here separately.

The first category includes each person’s unique personal characteristics and experiences, which affect that individual’s actions. Significant components within this category are prior related behavior and personal factors. Prior related behavior is important in influencing future behavior. Pender proposed that prior behavior has both direct and indirect effects on the likelihood of engaging in health-promoting behaviors. In particular, past behavior has a direct effect on the current health-promoting behavior through habit formation: Habit strength increases each time a behavior occurs. Prior behavior is proposed to indirectly influence health-promoting behavior through perceptions of self-efficacy, benefits, barriers, and activity-related affect or emotions (Pender, Murdaugh, & Parsons, 2006). Personal factors include biological factors such as age, body mass index, pubertal status, menopausal status, aerobic capacity, strength, agility, or balance; psychological factors include self-esteem, self-motivation, and perceived health status; and sociocultural factors include race, ethnicity, acculturation, education, and socioeconomic status. Some personal factors are amenable to change, whereas others are immutable (Pender et al., 2006).

The second category encompasses behavior-specific cognitions and affect, which serve as behavior-specific variables within the health promotion model. Behavior-specific variables are considered to have motivational significance. In the health promotion model, nursing interventions target these variables because they are amenable to change. The behavior-specific cognitions and affect identified in the health promotion model include (1) perceived benefits of action, (2) perceived barriers to action, (3) perceived self-efficacy, and (4) activity-related affect. Other cognitions fall into the category of interpersonal influences and situational influences. Sources of interpersonal influences on health-promoting behaviors include family, peers, and healthcare providers. Interpersonal influences include norms, social support, and modeling; they shape the person’s tendency to participate in health-promoting behaviors. Situational influences on health-promoting behavior include perceptions of available options, demand characteristics, and aesthetic features of the environment. Within Pender’s model, nursing plans are tailored to meet the needs of diverse patients based on assessment of prior behavior, behavior-specific cognitions and affect, interpersonal factors, and situational factors (Pender et al., 2006, pp. 54–56).

The third category within Pender’s model is the behavioral outcome. Commitment to a plan of action marks the beginning of a behavioral event. This commitment propels the person into the behavior unless that action is confounded by a competing demand that cannot be avoided or a competing preference that is not resisted. Interventions in the health promotion model focus on raising consciousness related to health-promoting behaviors, promoting self-efficacy, enhancing the benefits of change, controlling the environment to support behavior change, and managing the barriers to change. Health-promoting behavior, which is ultimately directed toward attaining positive health outcomes, is the product of the health promotion model (Pender et al., 2006, pp. 56–63). DQ: Middle-range theory or grand theory

Major Concepts of Nursing According to Pender


The person in the health promotion model refers to the individual who is the primary focus of the model. In Pender’s model, each person has unique personal characteristics and experiences that affect subsequent actions. It is recognized that individuals learn health behaviors within the context of the family and the community, which explains why the model for assessment includes components and interventions at the family and community levels, as well as the individual level (Pender, Murdaugh, & Parsons, 2002, 2006). This is taken a step further in the latest edition (Pender, Murdaugh, & Parsons, 2011), in which the term client refers to individuals, families, and communities who are all viewed as active participants in health promotion.


In the health promotion model, the environment encompasses the physical, interpersonal, and economic circumstances in which persons live. The quality of the environment depends on the absence of toxic substances, the availability of restorative experiences, and the accessibility of human and economic resources needed for healthful living. Socioeconomic conditions such as unemployment, poverty, crime, and prejudice have adverse effects on health, whereas environmental wellness is manifested by balance between human beings and their surroundings (Pender et al., 2006, p. 9; Pender et al., 2011, p. 8).


Health is viewed as a positive high-level state. According to Pender, the person’s definition of health for himself or herself is more important than any general definition of health (Pender et al., 2006; Sakraida, 2010). Health is viewed in the context of health promotion and disease prevention. Health promotion is behavior that is motivated by a desire to increase well-being and optimize human health potential, whereas disease prevention or health protection is behavior motivated by a desire to actively avoid illness, detect illness early, or maintain functioning within the constraints of illness (Pender et al., 2011, p. 5). Health promotion is viewed as a multidimensional concept that includes the dimensions of the individual, the family, the community, socioeconomic status, cultural factors, and environmental factors (Pender et al., 2011, pp. 6–8).


The role of the nurse in the health promotion model revolves around raising consciousness related to health-promoting behaviors, promoting self-efficacy, enhancing the benefits of change, controlling the environment to support behavior change, and managing the barriers to change (Pender et al., 2006, pp. 57–63). A major function of the APN role is the focus on health promotion. This model serves as a significantly pragmatic process for APNs to use to encourage health-promoting behaviors by patients and to address the benefits of change.

Analysis of the Health Promotion Model

The analysis and critique presented here comprise an examination of assumptions and propositions, as well as the analysis of clarity, simplicity, generality, empirical precision, and derivable consequences of Pender’s health promotion model.

Assumptions of the Health Promotion Model

Assumptions of the health promotion model reflect both nursing and behavioral science perspectives. The seven major assumptions emphasize the active role of the patient in shaping and maintaining health behaviors and in modifying the environmental context for health behaviors:

1. Persons seek to create conditions of living through which they can express their unique human potential.

2. Persons have the capacity for reflective self-awareness, including assessment of their own competencies. DQ: Middle-range theory or grand theory

3. Persons value growth in directions viewed as positive and attempt to achieve a personally acceptable balance between change and stability.

4. Persons seek to actively regulate their own behavior.

5. Persons in all their biopsychosocial complexity interact with the environment, both progressively transforming the environment and being transformed over time.

6. Health professionals constitute a part of the interpersonal environment, which influences persons throughout their life span.

7. Self-initiated reconfiguration of person–environment interactive patterns is essential for behavior change (Pender et al., 2002, p. 63).

Propositions of the Health Promotion Model

The health promotion model is based upon 14 theoretical propositions. These theoretical relationship statements provide a basis for research related to health behaviors:

1. Prior behavior and inherited and acquired characteristics influence health 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 commitment to action (a mediator of behavior), as well as 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 a specific health behavior.

6. Positive affect toward a behavior results in greater perceived self-efficacy, which can, in turn, result in increased positive affect.

7. When positive emotions or affect are associated with a behavior, the probability of commitment and action are 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. DQ: Middle-range theory or grand theory

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