Chapter 5: Compliance, Motivation, and Health Behaviors

• Chapter 5 focuses on compliance, motivation, and health behaviors in learners.
• The chapter aims to define compliance, adherence, and motivation in the context of learner behaviors.
• It also seeks to discuss related concepts and theories, identify incentives and obstacles, state axioms of motivation, and assess learner motivation levels.
• Strategies to improve compliance and adherence, comparing health behavior frameworks, and understanding the nurse's role in health promotion are also objectives.

Compliance vs Adherence

• Compliance involves observable behavior that can be directly measured.
• In healthcare, compliance is viewed with an authoritative approach, where the healthcare provider or educator holds authority, and the patient or learner is submissive.
• Adherence signifies support or commitment to a care plan and is notably more patient-centered.

Perspectives on Compliance

• Biomedical Theory links compliance with patient characteristics.
• Patient demographics, severity of disease, and treatment regimen complexity are considered.
• Behavioral/Social Learning Theory emphasizes external factors influencing patient adherence, including rewards, cues, contracts, and social support.
• Communication Models focus on the communication dynamics between the patient and healthcare provider to explain compliance.
• Rational Belief Theory proposes patients decide to comply by weighing treatment benefits against disease risks through cost-benefit analysis.
• Self-Regulatory Systems views patients as problem solvers.
• Behavior regulation is based on illness perception, cognitive skills, and past experiences in planning and coping.

Noncompliance and Nonadherence

• Noncompliance involves resistance to following a predetermined regimen.
• Noncompliant behavior includes blaming, being judgmental, and disobedience.
• Individuals tend to make excuses for noncompliance, even without a valid reason, placing themselves at unnecessary health risk and escalating healthcare costs.
• Nonadherence is resistance to following treatment recommendations mutually agreed upon and can be intentional or unintentional; it poses unnecessary health risks and may increase medical expenditures.

Reasons for Noncompliance

• Reasons for noncompliance remains unanswered.
• Knowledge, motivation, treatment factors, disease issues, lifestyle issues, sociodemographic factors, and psychosocial variables can affect noncompliance.
• According to the World Health Organization, reasons for nonadherence can be related to socioeconomics, patient-specific factors, condition issues, therapy-related factors and healthcare team or system issues.

Locus of Control

• Locus of Control signifies an individual's sense of responsibility for their behavior.
• Also is the extent to which motivation originates internally or is influenced by others externally.
• Dimensions of Locus of Control: internal, chance external, others external, and doctors external.
• It connects with compliance in therapeutic regimens, though not always.

Motivation

• Motivation is an internal state that initiates, guides, and sustains human behavior, influenced by internal and external factors, including implicit motivation.
• Implicit motivation involves progressing towards meeting a need or reaching a goal.
• Healthcare providers facilitate the learner's approach to desired goals, preventing delays.

Maslow's Motivational Theory

• Maslow's Motivational Theory addresses the complexity of motivation.
• Not all behavior is motivated.
• The Hierarchy of Needs includes physiological, safety, love/belonging, self-esteem, and self-actualization.
• Needs are organized by their level of potency.

Motivational Factors

• Creating incentives and reducing obstacles for learners poses challenges for healthcare professionals as educators.
• Facilitating or blocking factors influencing motivation include personal attributes, environmental factors and relationships.

More on Motivation

• Personal attributes influencing motivation can be physical, developmental, and psychological, shaping an individual's motivation to learn and views on change.
• Environmental influences: physical and attitudinal climate, learning environment, available human resources, and behavioral rewards.
• Pleasant, comfortable, and adaptable surroundings promote learning, while noise, confusion, interruptions, and lack of privacy detract.
• Learner relationships systems, including significant others, cultural identity, work, school, community, and teacher-learner interactions, influence an individual's motivation.

Motivational Axioms

• Axioms include state of optimal anxiety, learner readiness, realistic goal setting, learner satisfaction or success, and maintaining dialogue.
• Motivation axioms are premises upon which understanding a phenomenon is based, helping set the stage for learner motivation.
• These are rules that set the stage for motivation.
• This helps understanding the premises needed to promote motivation as a nurse educator.
• Optimal anxiety is the learner's ability to observe, focus attention, learn, and adapt, enhancing perception, concentration, abstract thinking, and information processing.
• Behavior in this state is directed at learning.
• Learner Readiness: Desire cannot be imposed.
• External forces are capable of influencing and promoting this readiness. Incentives must be specific to the learners.
• Realistic goals should align with needed behavioral changes.
• Mutual goal setting with the learner can reduce negative effects, where educators can set realistic expectations and standards.
• Learner Satisfaction/Success: Success promotes a sense of self esteem and satisfaction.
• Positive reinforcement leads to satisfaction and accomplishment.
• Inversely, focusing on negative performance can lead to low self-esteem.
• Uncertainty Reduction or Maintenance: Patients may be asked to make decisions about treatments and care options whose outcomes are unclear.
• Patients can either reduce or maintain uncertainty, but uncertainty should be reconceptualized in order to maintain current treatment if that is needed.

Assessing Motivation

• Assessment of motivation is part of a general health assessment that includes level of knowledge, client skills, decision-making capacity, and screening target populations.
• It follows a process involving educator judgment and includes both subjective (dialogue, nonverbal cues, self-reports) and objective (observation of expected behaviors) components.

Motivational Strategies

• Motivational strategies for the nurse as educator are extrinsically generated using specific incentives.
• Concept Mapping is a strategy to facilitate integration of newly acquired knowledge through diagrammatic "mapping," promoting interest and value for the learner.

ARCS Model

• ARCS model (Keller, 1983 ): create and maintain motivational strategies when designing the instructions.
• The ACRS model includes Attention, Relevance, Confidence, and Satisfaction.

Motivational Interviewing

• Motivational Interviewing is is used to support newly acquired information through mapping.
• This will strengthens an individual's motivation toward change.
• In MI, the nurse is not an authoritative figure, as the learners have greater autonomy.

Spirit of MI

• The core spirit of MI Includes Collaboration, Evocation, and Autonomy.
• The goal of M.I. is to help patients gain control when it comes to healthy lifestyle management.

Phases of Motivational Interviewing

• 1st Phase: the nurse helps the patient enhance intrinsic motivation for change.
• 2nd Phase: commitment to change is strengthened

Motivational Interviewing Principles

• The mnemonic OARS can describe Motivational Interviewing strategies.
• The Five General Principles of Motivational Interviewing (Miller & Rollnick, 2013):
  • Roll with resistance
  • Express empathy
  • Avoid argumentation
  • Develop discrepancy
  • Support self-efficacy
• Miller and Rollnick (2013) suggest the mnemonic OARS to describe these strategies:
  • Open-ended questioning
  • Affirmations of the positives
  • Reflective listening
  • Summaries of the interactions

Models and Theories

• Models and Theories can be used to explain and predict the health behavior of the patients
• Understanding these theories allows an educator to guide patients or help with motivation
  • Health Belief Model
  • Health Promotion Model
  • Self-Efficacy Theory
  • Protection Motivation Theory
  • States of Change Model
  • Theory of Reasoned Action
  • Theory of Planned Behavior
  • Therapeutic Alliance Model

The Health Belief Model

• This model was modified to address compliance with therapeutic regimens.
• The HBM explains and predicts health behaviors based on the patients’ beliefs about the health problem and the health behavior.
• The components are, individual perceptions, modifying factors, and likelihood of action.
• These include the subcomponents of perceived susceptibility or perceived severity of a specific disease.
• Modify factors: Demographic and Sociopsychological These include the subcomponents of perceived benefits of preventive action minus perceived barriers to preventive action.

Health Promotion Model

• Originally developed by Pender in 1987.
• The model is to assist nurses in understanding the major determinants of health behaviors as a basis for behavioral counseling to promote healthy lifestyles.
• The HPM describes major components and variables that influence health-promoting behaviors.
• Individual and Behavior specific

Self-Efficacy Theory

• Self-efficacy theory is based on a person’s expectations relative to a specific course of action.
• It is predictive and it helps to belive in your abilites.
• Four principal sources of the theory: Performance accomplishments, vicarious experiences, verbal persuasion, and emotional arousal

Protection Motivation theory

• Explains the behavioral change
• Theory has been used to test antecedents to health behaviors such as: Drug abuse, AIDS, Smoking, Sun protection, and Drinking behaviors

Stages of change model

• Also known as the transtheoretical model
• Include Precontemplation, Contemplation, Preparation, Action, Maintenance, and Termination

Reasoned Action

• Is considered a framework of social content.
• Can lead to belief attitude, and intention
• Motivation to comply with influential people

Planned Behavior

• The Theory of Planned Behavior added a third element to Theories of Reasons Action.
• The TRA and the TPB have been used to determine nurses' attitudes toward teaching particular health education topics.

Therapeutic Alliance Model

• Therapeutic alliance is formed between the caregiver and the care receiver in which the participants are viewed as having equal power.
• Shift towards self-determination and the individual is active and responsible.

Models for Health Education

• Selection of models can be based on Similarities and dissimilarities, the nurse as educator’s agreement with model conceptualizations, and Functional utility.
• Models have in common the salient factors of individual perceptions
• Important to patient when making decisions

Integration of models is also important

• Theories in education can also give the blueprint to an educator to deliver health care.
• Factors such as age come into play when trying to deliver healthcare.

Developmental Stages of the Learner

• Include PEDAGOGY (TEACHING CHILDREN), ANDRAGOGY (TEACHING ADULTS), GERAGOGY (TEACHING OLDER ADULTS)

Role of a Nurse

• The RN is an educator to promote the lifestyles in their care such as facilitator, change, contractor, organzier and evaluator.

Healthy People

• Composed of Four Goals: Prevent disease and injury, Achieve health equity, promote good health, and promote healthy developments.
• The evidence is less than adequate for implementing nursing interventions that specifically address the variables of compliance and motivation as related to health behaviors of the learner, with a limited State of Evidence being cited.
• Some evidence suggests that there is no clear definition of motivation and there is a lack in health risk studies.
• Forums for evidence-based teaching are important and needed.