1. Chapter 14 Theories From the Behavioral Sciences

2. 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

3. 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

4. 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.

5. 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

6. 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.

7. 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

8. 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.

9. 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.

10. 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.

11. 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.

12. 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

13. 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.

14. 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.

15. Maslow’s Hierarchy of Needs—(cont.)
Each individual must meet the “deficiency” needs—those that are essential for survival—before meeting higher level needs.

16. 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.

17. 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.

18. 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).

19. 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.

20. 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

21. 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.)

22. Question
Which of the following is NOT a construct of the Health Belief Model?
Perceived barriers
Perceived benefits
Perceived control
Perceived severity

23. 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.

24. 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

25. Health Belief Model—Resources
For more information:
usters/health%20communication/health_belief_model.do c/
_model.htm

26. 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.

27. 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

28. Question
In the Theory of Planned Behavior, intention is based on subjective norms, perceived control, and:
Attitude
Health knowledge
Motivation
Perceived value of action

29. Answer
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.

30. 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.

31. 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

32. Theory of Planned Behavior—Example
For more information: 20clusters/Health%20Communication/theory_planne d_behavior.doc/

33. 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.

34. 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

35. 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

36. 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

37. 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.

38. 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.

39. 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.

40. 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.

41. 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

42. 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)

43. 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

44. 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

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

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