Chapter 14

Copyright © 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins
Chapter 14Chapter 14
Theories From the BehavioralTheories From the Behavioral
SciencesSciences

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

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

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.

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

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.

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

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.

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.

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.

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.

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

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.

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.

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

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.

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.

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).

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.

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

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.)

Question
Which of the following is NOT a construct of the Health
Belief Model?
A.Perceived barriers
B.Perceived benefits
C.Perceived control
D.Perceived severity

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.

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

Health Belief Model—Resources
• For more information:
http://www.utwente.nl/cw/theorieenoverzicht/theory%20clust
http://changingminds.org/explanations/belief/health_belief_m

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.

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

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

Answer
A. 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.

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.

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

Theory of Planned Behavior—Example
For more information:
http://www.utwente.nl/cw/theorieenoverzicht/Theory
%20clusters/Health
%20Communication/theory_planned_behavior.doc/

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.

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

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

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

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.

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.

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.

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.

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

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)

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

(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

• 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

• 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

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