Compliance, Motivation, and Health Behaviors of the Learner
Eleanor Richards
CHAPTER HIGHLIGHTS
Compliance
Perspectives on Compliance
Locus of Control
Noncompliance
Motivation
Motivational Factors
Motivational Axioms
Assessment of Motivation
Motivational Strategies
Selected Models and Theories
Health Belief Model
Health Promotion Model (Revised)
Self-Efficacy Theory
Protection Motivation Theory
Stages of Change Model
Theory of Reasoned Action
Therapeutic Alliance Model
Models for Health Education
Similarities and Dissimilarities of Models
Educator Agreement with Model Conceptualizations
Functional Utility of Models
Integration of Models for Use in Education
The Role of Nurse as Educator in Health Promotion
Facilitator of Change
Contractor
Organizer
Evaluator
State of the Evidence
KEY TERMS
compliance
motivation
adherence
noncompliance
locus of control hierarchy of needs
motivational incentives
motivational axioms
concept mapping
motivational interviewing (MI)
READS
OARS
health belief model
health promotion model
self-efficacy theory
protection motivation theory
stages of change model
theory of reasoned action (TRA)
therapeutic alliance model
concordance
educational contracting
OBJECTIVES
After completing this chapter, the reader will be able to
Define the terms compliance, adherence, and motivation relative to behaviors of the learner.
Discuss compliance and motivation concepts and theories.
Identify incentives and obstacles that affect motivation to learn.
State axioms of motivation relevant to learning.
Assess levels of learner motivation.
Outline strategies that facilitate motivation and improve compliance.
Compare and contrast selected health behavior frameworks and their influence on learning.
Recognize the role of the nurse as educator in health promotion.
The concepts of compliance and motivation are used implicitly or explicitly in many health behavior models. This chapter discusses these concepts as they relate to health behaviors of the learner and presents an overview of selected theories and models for consideration in the teaching-learning process. The nurse as educator needs to understand which factors promote or hinder the acquisition and application of knowledge and what drives the learner to learn.
Factors that determine health behaviors and outcomes are complex. Knowledge alone does not guarantee that the learner will engage in health-promoting behaviors or that the desired outcomes will be achieved. The most well-thought-out educational program or plan of care cannot achieve the prescribed goals if the learner is not understood in the context of complex factors associated with compliance and motivation.
COMPLIANCE
The literature reveals continuing controversy about the use of the term compliance to describe patient behavior. Compliance means submission
or yielding to the recommendations or will of others. Defined as such, it has an authoritative undertone. Specifically, when applied to health care, it implies that the healthcare provider or educator is viewed as the authority, and the consumer or learner is in a submissive role, passively following recommendations. Many nurses object to this hierarchical stance because they believe that patients have the right to make their own healthcare decisions and not necessarily follow predetermined courses of action set by healthcare professionals.
or yielding to the recommendations or will of others. Defined as such, it has an authoritative undertone. Specifically, when applied to health care, it implies that the healthcare provider or educator is viewed as the authority, and the consumer or learner is in a submissive role, passively following recommendations. Many nurses object to this hierarchical stance because they believe that patients have the right to make their own healthcare decisions and not necessarily follow predetermined courses of action set by healthcare professionals.
Healthcare literature suggests that compliance is a statement of outcome and indicates achievement of a goal identified in a health-related regimen. Compliance, as an end result, differs from motivation, which is viewed as means to an end. For example, a teenager with an eating disorder may not be compliant with the prescribed daily caloric requirement because she may not have the desire or motivation to gain weight. Compliance with a health regimen is an observable behavior and as such can be directly measured. Motivation, by comparison, is a precursor to action that can be indirectly measured through behavioral consequences or results. Commitment or attachment to a regimen is known as adherence, which may be long-lasting. Both compliance and adherence refer to health-promoting regimens, which are determined largely by the healthcare provider. A subtle difference separates the terms compliance and adherence.
The term compliance implies obedience or passive acceptance of the healthcare regimen. In comparison, the term adherence implies support of or commitment to a plan of care. It is possible for an individual to comply with a regimen and not necessarily be committed to it. For example, a patient who is experiencing sleep disturbances may comply with medication as directed for a period of 1 week. The same patient may not continue to adhere to the regimen for an extended period of time, even though the sleep disturbances continue. In this situation, there is no support of the plan or commitment to follow through.
Nonadherence can be intentional or unintentional and can be affected by such variables as cognitive function, social support, and financial constraints. Erlen (2006) and colleagues continue to investigate “maintenance strategies, booster programs, and specific factors that can impede or enhance adherence” (p. 17). Both compliance and adherence are terms used in the measurement of health outcomes. Therefore, for the purpose of this chapter, these terms are used interchangeably.
Research, as evidenced by the multidisciplinary healthcare literature, has focused on the compliance or adherence of healthcare consumers to their healthcare plans. The number of studies on compliance reflects the importance of this concept to practice. Noncompliance confers an unnecessary health risk and can result in increased medical expenditures (Heiby, Lukens, & Frank, 2005). This phenomenon may also result from an emphasis on cost-effective health care, as seen, for example, in shorter lengths of hospital stays. The successes of educational programs in a fiscally responsible system ultimately are linked to measurement of patient compliance relative to outcomes.
Perspectives on Compliance
Theories and models of compliance, as described by Eraker, Kirscht, and Becker (1984) and Levanthal and Cameron (1987), can be viewed from various perspectives and are useful in explaining or describing compliance from a multidisciplinary approach, including psychology and education. These theories and models are as follows:
1. Biomedical theory, which links compliance with patient characteristics such as demographics, severity of disease, and complexity of treatment regimen.
2. Behavioral/social learning theory, which focuses on external factors that influence the patient’s adherence, such as rewards, cues, contracts, and social supports.
3. Communication models, which attempt to explain compliance on the basis of the communication between the patient and the healthcare professional. These models address aspects such as the feedback loop of sending, receiving, comprehending, retaining, and accepting information.
4. Rational belief theory, which suggests that patients make a decision to comply or not comply by weighing the benefits of treatment and the risks of disease through the use of cost-benefit logic.
5. Self-regulatory systems, in which patients are seen as problem solvers whose regulation of behavior is based on perception of illness, cognitive skills, and past experiences that affect their ability to plan and cope with illness.
Although these theories and models shed some light on the very complex issue of compliance, most sources agree that each of them has limitations and no one theory or model alone has proved to be superior to the others (Heiby et al., 2005; Munro, Lewin, Swart, & Volmink, 2007). In recent years, researchers have attempted to use a multivariate approach to explaining compliance. For example, Heiby et al. (2005) have proposed the health compliance-II model, which incorporates variables from several theories and models. Further research is needed to identify a model that incorporates some of the multiple variables described subsequently.
Locus of Control
The authoritative aspect of compliance infers that the educator makes an attempt to control, in some degree, decision making on the part of the learner. Some models of compliance have attempted to balance the issue of control by using terms such as mutual contracting (Steckel, 1982) or consensual regimen (Fink, 1976).
One way to view the issue of control in the learning situation is through the concept of locus of control (Rotter, 1954) or health locus of control (Wallston, Wallston, & DeVellis, 1978). Locus of control refers to an individual’s sense of responsibility for his or her own behavior and the extent to which motivation to take action originates from within the self (internal) or is influenced by others (external). Through objective measurement, individuals can be categorized as internals, whose health behavior is self-directed, or externals, for whom others are viewed as more powerful in influencing health outcomes. Externals believe that fate is a powerful external force that determines life’s course, whereas internals believe that they control their own destiny. For instance, an external might say, “Osteoporosis runs in my family, and it will catch up with me.” An internal might say, “Although there is a history of osteoporosis in my family, I will have necessary screenings, eat an appropriate diet, and do weight-bearing exercise to prevent or control this problem.”
Researchers in the health professions have attempted to link locus of control with compliance, but study results in this area have been mixed. Locus of control has been linked to compliance in some therapeutic regimens but has shown no relationship in others (Rosno, Steele, Johnston, & Aylward, 2008; Sin-Jae, Sug-Joon, & Tae-Woo, 2008). Shillinger (1983) suggests that different teaching strategies are indicated for internals and externals. The literature, however, remains inconclusive as to the nature of the relationship between compliance and internals versus externals.
Noncompliance
Noncompliance describes resistance of the individual to follow a predetermined regimen. It often results in blaming behavior when patient
goals are not achieved (Yach, 2003). Ward-Collins (1998) notes that noncompliance can be a highly subjective judgmental term sometimes used synonymously with the terms noncooperative and disobedient. Helme and Harrington (2004) studied patients who were noncompliant with their diabetes regimen and found that although the largest number of people admitted their failure to comply with their healthcare plan, many offered excuses or justifications and some denied that noncompliance had occurred. Even though in this study participants had nothing to lose by admitting their noncompliance, many felt the need to explain or deny their failure to follow orders.
goals are not achieved (Yach, 2003). Ward-Collins (1998) notes that noncompliance can be a highly subjective judgmental term sometimes used synonymously with the terms noncooperative and disobedient. Helme and Harrington (2004) studied patients who were noncompliant with their diabetes regimen and found that although the largest number of people admitted their failure to comply with their healthcare plan, many offered excuses or justifications and some denied that noncompliance had occurred. Even though in this study participants had nothing to lose by admitting their noncompliance, many felt the need to explain or deny their failure to follow orders.
The literature is replete with studies on patient noncompliance. Nevertheless, the question of why clients are noncompliant remains largely unanswered, primarily because of the complexity of the issue. Noncompliance can be related to patient issues such as knowledge or motivation, treatment factors such as side effects, disease issues such as prognosis, lifestyle issues such as transportation, sociodemographic factors such as social and economic status, and psychosocial variables such as depression and fear (Rosner, 2006).
The educator’s self-awareness relative to the learner’s personality characteristics and previous history of compliance to health regimens could play an important role in the educational process. In an overview of the nursing literature reported by Russell, Daly, Hughes, and op’t Hoog (2003, p. 282), noncompliance was categorized as follows:
1. A patient problem to be solved by nursing interventions
2. Rationalization—critical of the term noncompliance but acknowledges its importance in healthcare issues
3. Evaluative—expresses concern about the term but offers various perspectives
Russell et al. (2003) note that the “labeling of non-compliance is predominantly based on nurses’ opinions of patients’ behavior” (p. 283). The results of this intervention, rationalization, and evaluative review support a patient-centered approach that challenges nurses not to reeducate or coerce, but rather to embrace a paradigm shift that changes patients’ lives rather than their health outcomes. These authors conclude that nurses need to act as advocates and acknowledge the importance of patients’ self-knowledge and decision making. In light of this discussion, nursing research targeted at positively influencing lifestyles rather than specific health behaviors is an area that warrants investigation.
The expectation of total compliance in all spheres of behavior and at all times is unrealistic. At times, noncompliant behavior may be desirable and could be viewed as a necessary defensive response to stressful situations. The learner may use time-outs as the intensity of the learning situation is maintained or escalates. This mechanism of temporary withdrawal from the learning situation may actually prove beneficial. Following withdrawal, the learner could reengage, feeling renewed and ready to continue with an educational program or regimen. Viewed in this way, noncompliance is not an obstacle to learning and does not carry a negative connotation.
MOTIVATION
Motivation, from the Latin word movere, means to set into motion. Motivation has been defined as a psychological force that moves a person toward some kind of action (Haggard, 1989). It has also been described as a willingness of the learner to embrace learning, with readiness as evidence of motivation (Redman, 2007). According to Kort (1987), motivation is the result of both internal and external factors and not the result of external manipulation alone. Implicit in motivation is movement in the direction of meeting a need or toward reaching a goal.
Lewin (1935), an early field theorist, conceptualized motivation in terms of positive or negative movement toward goals. Once an individual’s equilibrium is disturbed, such as in the case of illness, forces of approach and avoidance may come into play. Lewin noted that if avoidance endured in an approach-avoidance conflict, there would be negative movement away from a goal. His theory implies the existence of a critical time factor relative to motivation. This time factor, however, is generally not a serious consideration in motivational models of health behavior or motivational research.
Ideally, the nurse educator’s role is to facilitate the learner’s approach toward a desired goal and to prevent untimely delays. For example, nursing staff may request an in-service program about evidence-based practice. The in-service nurse educator may delay this request to the point that the staff loses interest in the topic. Although untimely delays may be beyond the control of the educator, every effort should be made to capitalize on the staff’s desire and readiness to learn.
Maslow (1943), another well-known early theorist, developed a theory of human motivation that is still widely used in the social sciences. The major premises of Maslow’s motivation theory are integrated wholeness of the individual and a hierarchy of goals. Acknowledging the complexity of the concept of motivation, Maslow noted that not all behavior is motivated and that behavior theories are not synonymous with motivation. Many determinants of behavior other than motives exist, and many motives can be involved in one behavior. Using the principles of a hierarchy of needs—physiological, safety, love/belonging, esteem, and self-actualization—Maslow noted the relatedness of needs, which are organized by their level of potency. Some individuals are highly motivated, whereas others are weakly motivated. When a need is fairly well satisfied, then the next potent need emerges. An example of the hierarchy of basic needs is the potent need to satisfy hunger. This need may be met by the nurse assisting the patient who is post stroke with feeding. The nurse-patient interaction may also satisfy the next most potent needs, those of love/belonging and esteem.
Relationships exist between motivation and learning; between motivation and behavior; and among motivation, learning, and behavior. Motivation may be viewed in relation to learning in many ways. Redman (2007) categorizes theories of motivation that direct learning as behavioral reinforcers, need satisfaction, reduction of discomforting inconsistencies as a result of cognitive dissonance, allocation of causal factors known as attributions, personality in which motivation is acknowledged to be a stable characteristic, expectancy theory encompassing value and perceived chance of success, and humanistic interpretations of motivation that emphasize personal choice. Each theory attempts to address the complex and somewhat elusive quality of motivation.
Motivational Factors
Factors that influence motivation can serve as either incentives or obstacles to achieve desired behaviors. Both creating incentives and decreasing obstacles to motivation pose a challenge for the nurse as educator. The cognitive (thinking processes), affective (emotions and feelings), and psychomotor (skill behavior) domains as well as the social circumstances of the learner can be influenced by the educator, who can act as either a motivational facilitator or blocker.
Motivational incentives need to be considered in the context of the individual. What may be a motivational incentive for one learner may be a motivational obstacle to another. For example, a student assigned to work with a woman who is elderly may be motivated when the student holds older persons in high regard. Another student may be motivationally blocked by the same emotional domain because previous experiences with older women, such as a grandmother, were unrewarding.
Facilitating or blocking factors that shape motivation to learn can be classified into three major categories, which are not mutually exclusive:
1. Personal attributes, which consist of physical, developmental, and psychological components of the individual learner
2. Environmental influences, which include the physical and attitudinal climate
3. Learner relationship systems, such as those of significant other, family, community, and teacher-learner interaction
PERSONAL ATTRIBUTES
Personal attributes of the learner—such as developmental stage, age, gender, emotional readiness, values and beliefs, sensory functioning, cognitive ability, educational level, actual or perceived state of health, and severity or chronicity of illness—can shape an individual’s motivation to learn. Functional ability to achieve behavioral outcomes is determined by physical, emotional, and cognitive dimensions. The individual’s perception of disparity between the current and expected states of health can be a motivating factor in health behavior and can drive readiness to learn.
The learner’s views about the complexity or extent of changes that are needed can shape motivation. Values, beliefs, and natural curiosity can be firmly entrenched and enduring factors that can also shape desire to learn new behaviors. Other factors, such as sensory input and processing of information and short-term and long-term memory, can affect motivation to learn as well. Emerging interest about male-female behavioral and learning differences indicates the need for in-depth research on gender-related characteristics that affect motivation to learn.
ENVIRONMENTAL INFLUENCES
Physical characteristics of the learning environment, accessibility and availability of human and material resources, and different types of behavioral rewards all combine to influence the motivational level of the individual. The environment can create, promote, or detract from a state of learning receptivity. Pleasant, comfortable, and adaptable individualized surroundings, for example, can promote a state of readiness to learn. Conversely, noise, confusion, interruptions, and lack of privacy can interfere with the capacity to concentrate and to learn.
The factors of accessibility and availability of resources include physical and psychological aspects. Can the client physically access a health facility, and once there, will the healthcare personnel be psychologically available to the client? Psychological availability refers to whether the healthcare system is flexible and sensitive to patients’ needs. It includes factors such as promptness of services, sociocultural competence, emotional support, and communication skills. Attitude influences the client’s engagement with the healthcare system.
The manner in which the healthcare system is perceived by the client affects the client’s willingness to participate in health-promoting behaviors. Behavioral rewards permeate the foundations of the learner’s motivation. Rewards can be extrinsic, such as praise or acknowledgment from the educator or caretaker. Alternatively, they can be intrinsically based, taking the form of feelings of a personal sense of fulfillment, gratification, or self-satisfaction.
RELATIONSHIP SYSTEMS
Family or significant others in the support system; cultural identity; work, school, and community roles; and teacher-learner interaction are all relationship-based factors that influence an individual’s motivation. The interactional aspects of motivation are perhaps the most salient because the learner always exists in the context of interlocking relationship systems. Individuals are viewed in the context of family/community/cultural systems that have lifelong effects on the choices that
individuals make, including healthcare seeking and healthcare decision making. These significant other systems may have an even greater influence on health outcomes than commonly acknowledged, and the nurse, when in the role of educator, needs to take into account the health-promoting use of these systems. Collectively, these factors interact to address the motivation of the learner. They are not comprehensive theory constructs, but rather forces that act on motivation, serving to facilitate or block the desire to learn.
individuals make, including healthcare seeking and healthcare decision making. These significant other systems may have an even greater influence on health outcomes than commonly acknowledged, and the nurse, when in the role of educator, needs to take into account the health-promoting use of these systems. Collectively, these factors interact to address the motivation of the learner. They are not comprehensive theory constructs, but rather forces that act on motivation, serving to facilitate or block the desire to learn.
Motivational Axioms
Axioms are premises on which an understanding of a phenomenon is based. The nurse as educator needs to understand the premises involved in promoting motivation of the learner. Motivational axioms are rules that set the stage for motivation. They include (1) the state of optimal anxiety, (2) learner readiness, (3) realistic goal setting, (4) learner satisfaction/success, and (5) uncertainty-reducing or uncertainty-maintaining dialogue.
STATE OF OPTIMAL ANXIETY
Learning occurs best when a state of moderate anxiety exists. In this optimal state for learning, the learner’s ability to observe, focus attention, learn, and adapt is operative (Peplau, 1979). Perception, concentration, abstract thinking, and information processing are enhanced. Behavior is directed at a learning or challenging situation. Above this optimal level, at high or severe levels of anxiety, the ability to perceive the environment, concentrate, and learn is reduced. A moderate state of anxiety can be comfortably managed and is known to promote learning (Kessels, 2003; Ley, 1979; Stephenson, 2006). As anxiety escalates, however, attention to external stimuli is reduced, the learner becomes increasingly self-absorbed, and behavior becomes defensively reactionary rather than being cognitively generated (Shapiro, Boggs, Melamed, & Graham-Pole, 1992).
For example, a patient who has been recently diagnosed with insulin-dependent diabetes and who has a high level of anxiety will not respond at an optimal level of retention of information when instructed about insulin injections. When the nurse is able to aid the client in reducing anxiety through techniques such as guided imagery, use of humor, or relaxation tapes, the patient will respond with a higher level of information retention.
LEARNER READINESS
Desire to move toward a goal and readiness to learn are factors that influence motivation. Desire cannot be imposed on the learner. It can, however, be critically influenced by external forces and be promoted by the nurse as educator. Incentives are specific to the individual learner. An incentive for one individual can be a deterrent to another. For example, suggesting a method of weight reduction that includes physical exercise may be an incentive for one client, while totally unappealing for another. Incentives in the form of reinforcers and rewards can be tangible or intangible, external or internal.
Acting as a facilitator to the learner, the nurse as educator offers positive perspectives and encouragement, which shape the desired behavior toward goal attainment. By ensuring that learning is stimulating, making information relevant and accessible, and creating an environment conducive to learning, educators can enhance motivation to learn.
REALISTIC GOALS
Goals that are within a person’s grasp and possible to achieve are goals toward which an individual will work. In contrast, goals that are beyond the person’s reach are frustrating and counterproductive. Setting unrealistic goals that lead to loss of valuable time can set the stage for the learner to give up.
Setting realistic goals is a motivating factor. The belief that one can achieve the task set before
him or her facilitates behavior geared toward achieving that goal. Goals should parallel the extent to which behavioral changes are needed. Determining what the learner wants to change is a critical factor in setting realistic goals. Mutual goal setting between learner and educator reduces the negative effects of hidden agendas or the sabotaging of educational plans.
him or her facilitates behavior geared toward achieving that goal. Goals should parallel the extent to which behavioral changes are needed. Determining what the learner wants to change is a critical factor in setting realistic goals. Mutual goal setting between learner and educator reduces the negative effects of hidden agendas or the sabotaging of educational plans.
LEARNER SATISFACTION/SUCCESS
The learner is motivated by success. Success is self-satisfying and feeds the learner’s self-esteem. In a cyclical process, success and self-esteem escalate, moving the learner toward accomplishment of additional goals. When a learner feels good about step-by-step accomplishments, motivation is enhanced. For example, in the instructor-student relationship, evaluations can be a valuable method of promoting learner success. Clinical evaluations, when focused on demonstration of positive behaviors, can encourage movement toward performance goals. Focusing on successes as a means of positive reinforcement promotes learner satisfaction and instills a sense of accomplishment. Conversely, focusing on weak clinical performance can reduce students’ self-esteem.
UNCERTAINTY REDUCTION OR MAINTENANCE
Uncertainty is a common experience in the healthcare arena. Healthcare consumers and health professionals alike are often asked to make decisions about treatments and care whose outcomes are unclear. An individual’s response to this type of uncertainty may vary and depends on the individual’s characteristics (Politi, Han, & Col, 2007).
Uncertainty (as well as certainty) can be a motivating factor in the learning situation. Individuals may have ongoing internal dialogues that can either reduce or maintain uncertainty. Individuals carry on “self-talk”; they think things through. When a person wants to change a state of health, behaviors often follow a dialogue that examines uncertainty, such as “If I stop smoking, then my chances of getting lung cancer will be reduced.” When the probable outcome of health behaviors is more uncertain, behaviors may maintain uncertainty. The person might say, “I am not sure that I need this surgery because the survival rates are no different for those who had this surgery and those who did not.” Some learners may maintain current behaviors, given probabilities of treatment outcomes, thereby maintaining uncertainty.
Mishel (1990) reconceptualizes the concept of uncertainty in illness. She views uncertainty as a necessary and natural rhythm of life, rather than an adverse experience. Uncertainty in sufficient concentration influences choices and decision making, and it can capitalize on receptivity or readiness for change. Premature uncertainty reduction can be counterproductive to the learner who has not sufficiently explored alternatives. For example, when a staff nurse is uncertain about positions for catheterizing a female client who is debilitated and is presented with alternatives, then a thinking dialogue is carried out. If the decision to use a particular position is not premature, then uncertainty will promote exploration of alternative positions.
Assessment of Motivation
How does the nurse know when the learner is motivated? As a generic concept, assessment of motivation to learn has not been adequately addressed in the literature. The lack of adequate conceptually based measurement tools could be a factor in this neglect.
Redman (2001) views motivational assessment as a part of general health assessment and states that it includes such areas as level of knowledge, client skills, decision-making capacity of the individual, and screening of target populations for educational programs. The educator can pose several questions in terms of the learner, such as those focusing on previous attempts, curiosity,
goal setting, self-care ability, stress factors, survival issues, and life situations. Motivational assessment of the learner needs to be comprehensive, systematic, and conceptually based. Cognitive, affective, physiological, experiential, environmental, and learning relationship variables need to be considered. Table 6-1 shows parameters for a comprehensive motivational assessment of the learner.
goal setting, self-care ability, stress factors, survival issues, and life situations. Motivational assessment of the learner needs to be comprehensive, systematic, and conceptually based. Cognitive, affective, physiological, experiential, environmental, and learning relationship variables need to be considered. Table 6-1 shows parameters for a comprehensive motivational assessment of the learner.
These multitheory-based parameters incorporate several perspectives, including Bandura’s (1986) construction of incentive motivators; Ajzen and Fishbein’s (1980) intent and attitude; Becker, Drachman, and Kirscht’s (1974) notion of likelihood of engaging in action; Pender’s (1996) commitment to a plan of action; and Barofsky’s (1978) focus on alliance in the learning situation. Additionally, the presence of cognitions in the form of facilitative beliefs proposed by Wright, Watson, and Bell (1996) provides a comprehensive and multidimensional assessment.
This multidimensional guide allows for assessment of the level of learner motivation. If responses to dimensions are positive, the learner is likely to be motivated.
This multidimensional guide allows for assessment of the level of learner motivation. If responses to dimensions are positive, the learner is likely to be motivated.
TABLE 6-1 Comprehensive Parameters for Motivational Assessment of the Learner | ||||||||||||
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Assessment of learner motivation involves the judgment of the educator because teaching-learning is a two-way process. In particular, motivation can be assessed through both subjective and objective means. A subjective means of assessing level of motivation is through dialogue. By being present and using therapeutic communication skills, the nurse can obtain verbal information from the client, such as “I really want to maintain my weight” or “I want to be able to take care of myself.” Both of these statements indicate an energized desire with direction of movement toward an expected health outcome. Nonverbal cues also can indicate motivation, such as browsing through lay literature about diet strategies. Likewise, a staff member or student may express a verbal desire to know more about a specific advanced procedure. A nonverbal motivational cue might be expressed by the staff member or student carefully observing a senior nurse or clinical specialist performing an advanced technique, for example.
Measurement of motivation is another aspect to be considered. Subjective self-reports indicate the level of motivation from the learner’s perspective. If desired, self-report measurements could be developed for educational programs. Objective measurement of motivation—an indirect measurement —can be quantified through observation of expected behaviors, which are the consequence of motivation. These behaviors can be observed in increments as the learner moves toward preset realistic health or practice goals.
Motivational Strategies
Finding the spark that motivates the learner to learn is challenging to the educator. The question remains, How does an educator motivate a seemingly unmotivated individual or help a motivated person to remain motivated? As noted earlier, incentives viewed as appeals or inducements to motivation can be either intrinsically or extrinsically generated. Incentives and motivation are both stimuli to action. Bandura (1986), for example, associates motivation with incentives. He notes, however, that intrinsic motivation, although highly appealing, is elusive. Only rarely does motivation occur without extrinsic influence. Green and Kreuter (1999) note that “strictly speaking we can appeal to people’s motives, but we cannot motivate them” (p. 30). Extrinsic incentives are used for motivational strategizing in the educational situation.
Cognitive evaluation theory (Ryan & Deci, 2000) posits that knowing how to foster motivation is essential because educators cannot rely on intrinsic motivation to promote learning. They note, however, that autonomy and competence are intrinsic motivators that can be enhanced by selected teaching strategies. One contemporary nursing educational strategy suggested as a means to promote motivation is concept mapping, which enables the learner to integrate previous learning with newly acquired knowledge through diagrammatic “mapping.” As a motivational technique, concept mapping facilitates the acquisition of complex new knowledge through visual links that acknowledge previous learning. Learner interest is sustained by perceived competence and autonomy. Concept mapping, as a less instructor-regulated learning activity, promotes interest and value on behalf of the learner. A review of the health professions’ literature indicates that students and faculty find concept mapping to be a valuable learning exercise (Hunter Revell, 2012; Taylor & Littleton-Kearney, 2011; Torre et al., 2007; Wilkes, Cooper, Lewin, & Batts, 1999).
Motivational strategies for the nurse as educator are extrinsically generated through the use of specific incentives. The critical question for the nurse as educator to ask is, “Which specific behavior, under which circumstances, in which time frame, is desired by this learner?” Strategizing begins with a systematic assessment of learner motivation, like that outlined in Table 6-1. When
an applicable dimension is absent or reduced, incentive strategizing is likely to move the individual away from the desired outcome. When considering strategies to improve learner motivation, Maslow’s (1943) hierarchy of needs also can be taken into consideration. An appeal can be made to the innate need for the learner to succeed, known as achievement motivation (Atkinson, 1964).
an applicable dimension is absent or reduced, incentive strategizing is likely to move the individual away from the desired outcome. When considering strategies to improve learner motivation, Maslow’s (1943) hierarchy of needs also can be taken into consideration. An appeal can be made to the innate need for the learner to succeed, known as achievement motivation (Atkinson, 1964).
In an educational setting, clear communication, including clarification of directions and expectations, is critical. Organization of material in a way that makes information meaningful to the learner, environmental manipulation, positive verbal feedback, and provision of opportunities for success are motivational strategies proposed by Haggard (1989). Reducing or eliminating barriers to achieve goals is an important aspect of maintaining motivation.
One model developed by Keller (1987), known as the attention, relevance, confidence, and satisfaction (ARCS) model, focuses on creating and maintaining motivational strategies used for instructional design. This model emphasizes strategies that the educator can use to effect changes in the learner by creating a motivating learning environment:
Attention introduces opposing positions, case studies, and variable instructional presentations.
Relevance capitalizes on the learners’ experiences, usefulness, needs, and personal choices.
Confidence deals with learning requirements, level of difficulty, expectations, attributions, and sense of accomplishment.
Satisfaction pertains to timely use of a new skill, use of rewards, praise, and self-evaluation.
In motivational strategizing, it would also be beneficial to consider Damrosch’s (1991) proposal that client health beliefs, personal vulnerability, efficacy of proposed change, and ability to effect the change are important in patient education efforts.
Beliefs are a major construct proposed by Wright et al. (1996) as the heart of healing in families. Facilitating beliefs can promote a desired change, whereas constraining beliefs can restrict options. Challenging constraining beliefs and promoting facilitating beliefs are, therefore, offered as motivational strategies.
An understanding of the individual’s mental representations or beliefs is also foundational to the commonsense model in the representational approach to patient education (Levanthal & Diefenbach, 1991). Beliefs constitute an underacknowledged and understudied phenomenon that needs to be further developed in the education literature in terms of motivational strategizing.
Motivational interviewing (MI) is a client-centered, directive counseling method in which clients’ intrinsic motivation to change is enhanced by exploring and resolving their ambivalence toward behavior change (Miller & Rollnick, 2002). Dart (2011) states that “motivational interviewing fits perfectly into the nursing profession” (p. 23) and represents a caring, respectful tool with which to promote behavior change. MI is a rapidly diffusing, empirically supported approach to health behavior change (Antiss, 2009). Both an assessment strategy and an intervention, MI supports client self-esteem and self-efficacy though emphasis on the client’s own reasons and values for change (Miller, 2004).
According to Miller (2010), the theoretical underpinnings of MI include Festinger’s (1957) cognitive dissonance theory, Bem’s (1967) self-perception theory, and Bandura’s (1977b) self-efficacy theory. Carl Rogers’s (1951) work on nondirective counseling and the FRAMES set of data about the effective components of brief interventions for change (Bien, Miller, & Tonigan, 1993) also provide foundational relevancy for this counseling
method (Miller, 2010), as does self-determination theory (Markland, Ryan, Tobin, & Rollnick, 2005). The MI approach integrates well with two health behavior models discussed later in this chapter: the transtheoretical model of change (Prochaska & DiClemente, 1982) and the therapeutic alliance model (Barofsky, 1978).
method (Miller, 2010), as does self-determination theory (Markland, Ryan, Tobin, & Rollnick, 2005). The MI approach integrates well with two health behavior models discussed later in this chapter: the transtheoretical model of change (Prochaska & DiClemente, 1982) and the therapeutic alliance model (Barofsky, 1978).
MI was initially used in substance abuse treatment with adults, where it was developed as a reaction to the confrontational methods used in that field in the 1970s and 1980s. In this counseling approach, the nurse as educator avoids telling a patient what he or she needs do. Rather, the interview is a collaborative venture between nurse and patient whereby a positive atmosphere is created through a partner-like relationship. The nurse “guides” rather than “directs” the patient. This approach stands in contrast to the classic relationship of “expert provider” and “passive recipient” (Miller, 2004) that is often seen in the traditional medical model. Table 6-2 includes a list of useful questions for nurses to ask patients that reinforce the “guiding” nature of this counseling approach.
TABLE 6-2 Top 10 Useful Questions in Motivational Interviewing | ||
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