Theoretical and Scientific Foundations of Nursing

Chapter 14 Theories From the Behavioral Sciences 319

Health Belief Model Thc HBM ,,-,1~ onc of rhc tirst modcb th.it .\d,1pred thcories from rh,: bch.iviur.11 science:. to predict hcalth bch.wior:,. Thi~ ,,·,1s dune by focusing on the artirndes .md beliefs of indiYiduab. The HBM \\',\~ origin.1lly dn·cloped in the l 9;;0s by .1 group of social psychologists working for rhc l1 .S. Public He.11th Sen·icc who ,,·.1med to improve the public's use of prc,·cnri,·e ser\'iccs ( Roscmtock, 197-! ). Their J~sumption was that people kar disease .111d th,1t he.11th aaions \\Tfc mori,·atcd in relation to the degree oftht'. fr.1r .rnd the bcncfir:- obt.1incd. The HBM cxplained health bchaYior in tcrms of ~cn:ral construct~: pcrcei\'ed su~ccptibility of the he.1lrh problem, pcrccivcd sc,·crity, pcrcciYo:d bcno:tit~, pcrceiYo:d barriers, .md cuc~ to ,\ction ( Roscnstock, 1990 I.

Pcr...-cin,·d :msccptibilitY rdcrs to one's opinion of ...-h.mce~ of getting,\ condition, wherc,1~ pcrcci,·cd seYo:rity is one's opinion of how saious a condition .md ir~ scqucl.lc .1re. One·~ opinion of the cftic.1cy of the .1lh·iscd ,1ctinn to reduce ri~k or scriousnes~ of impJct is known a.s pcrcciYcd bcncfits. Perccin:d barriers an: one\ opinion of tho: tangible and psyd1ologic.1l cmt of thc .1d, i~cd ,Ktion ( Rosenstock, 197-! I. Thesc four concepts were propo!>cd .h .1ccounting for people'!> rcadirn:s~ to ,Ktion. Thus, .mother concept ,,·,1s idenrificd .1~ "cuc!> ro acrion." The~i: ..:uc!> ru action would .1..:ti,·.u,: the rc,1dincss rn .1ct .111d stimul.irc m·crt beh.l\'ior~ ( Roscnstock, 1990; C. 5. Skinner, Tiro, & Champion, 2015) ( Figure 14-1 ).

In 1988, Rosenstock ,1ddcd ,Ull>thcr ..:oncept ro the H Br-I. which hc identificd as ~t:11:~ffi.:~Ky. Sdf-cfficacy i~ orn: \ (Onlilkncc in the ability ro successfully pi;rform .rn .1ction. Thi!> con..:ept wa!> uscd to help the H B1vl bctrer fir thc challenge~ of changing habiru,11, unhealthy bchaYion, !>Udl .1~ smoking, m·creating, and being sedentary ( C. S. Skinner ct al., 2015). T.1blc l-!-3 mnm1.uizes tho: major concepb of the HBi\ I.

320 Unit Ill Shored Theories Used by Nurses

Individual Perceptions

Perceived susceptibility to disease X

Perceived seriousness (severity) of disease X

Modifying Factors

Demographic variables (age, sex. race, ethnicity, etc.)

Sociopsychological variables (personality. social class, peer and reference-group pressure, etc.)

Structural variables (knowledge about the disease. prior contact with the disease, etc.)

t Perceived threat of

disease X

t Cues to action

Mass media campaigns

Advice from others Reminder postcard from physician or dentist

Illness of family member or friend

Newspaper or magazine article

Figure 14-1 The Health Belief Model.

Ltkeliih.ood of Action

Perceived 'benefits of preventive action

minus

Perceived 1barrlers to preventive action

l Likelihoo.d of taking

recommended pr.eventive health action

[From Becker, M . H., Haefner. D. P .. Kasi, S. V, K1rschr J. P., Mo,mon. L.A .. & Rosensteel. I. M. [ 1977]. Selected psychosoc1ol models and correlates of individual heohh-reloted behaviors Medical Care. 15 27- 46 with permission.I

Chapter 14 Theories From the Behavioral Sciences 321

Table 14-3 Health Belief Model Concepts Concept

Perceived susceptibility

Perceived severity

Perceived benefits

Perceived barriers

Cues to action

Self-efficacy

Definition

Subjective risk of contracting o condition; belief or opinion regarding chances of acquiring o health problem or threat

Concern related to the seriousness of a health condition end understanding of potential difficulties the condition might cause; belief or perception of seriousness or consequences of o health threat or condition

Beliefs related to the effectiveness of preventive actions; opinion that changing behovior(s) may reduce the treat

Perception of the obstacles to changing behavior; opinion related to tangible and/or psychological costs of action

A stimulus {external or internal) thot triggers health-related behaviors; something that makes the individual aware of o health threat

Belief that one hos the ability to change one's behaviors; recognition that personal health practices and choices con positively influence health

Examples

Does o teenage girl believe she will get pregnant during o single sexual encounter? Does ,on elderly man believe he will get the flu this winier? Does o middle-oged woman with o strong family history of breast cancer believe that she is vulnerable?

A teenage girl believes that pregnancy would change her life dramatically. An elderly men understands that pneumonia is a potential complication of the flu. A middle-oged woman knows her grandmother died of breast cancer.

The teenage girl knows that using contraception will dramatically reduce the chances of o pregnancy. The elderly man believes that flu shots ore effective in preventing illness. The middle-oged women recognizes that yearly mammograms ore effective in reducing deaths from breast cancer.

The teenage girl may be embarrassed about going too clinic to obtain contraceptives. The elderly man may not have transportation to toke him to the clinic to receive o flu shot. The middle-aged woman's insurance does not cover the cost of mommogroms.

The teenage girl attends o school-sponsored program on problems encountered by teenage mothers. The elderly mon sees a posted flyer that o mobile van will be nearby the following week to provide free flu shots. The middle-aged women learns from a public service radio ad that low<ost mammography is available at o nearby hospital.

The teenage girl decides to postpone intercourse. The elderly men attends the shot clinic provided by the mobile van. The middle-oged woman makes on appointment for a mammogram.

393 Chapter 17 Theories, Models, and Frameworks From Leadership and Management

Planned Change Theory Lewin ( 1951) described a method in his field theory that provides a basis for consid- ering the process of planned change. Planned change occurs by design, as opposed to change that is spontaneous or that occurs by happenstance or by accident. When Lewin's process is used correctly and in its entirety by a group or a system, effective change is implemented.

Central to Lewin's theories on planned change are the concepts offield and force. Afield can be viewed as a system; therefore, when change occurs in one part or aspect of the system, the whole system must be examined to determine tl1e effect of that change. Force is defined as a directed entity that has the characteristics of direction, focus, and strength. Lewin (1951 ) states that change is a move from the status quo that results in a disruption in the balance of forces or disequilibrium between oppos- ing forces.

According to Lewin (1951 ), there are two forces involved in change, driving forces and restraining forces. As the name implies, a driving force encourages or facili- tates movement to a new direction, goal, or outcome. A restraining force has the op- posite effect; restraining forces block or impede progress toward the goal. In planned change, driving forces should be identified and accentuated. If possible, restraining forces should also be identified and minimized to achieve the desired outcome or change. Lewin describes effective change as the return to equilibrium as a result of balancing opposing forces. Ifdriving forces and restraining forces can be identified, it may be possible to predict if and when change would be successful. Lewin identifies three phases that must occur if planned change is to be successful: unfreezing the sta- tus quo, moving to a new state, and refreezing the change to make it permanent. In the unfreezing stage, individuals involved must be informed of the need for change and should agree that change is needed. Change, particularly in the work environ- ment, often leads to feelings of uneasiness , uncertainty, and loss of control. Change, just for the sake of change, is viewed by most individuals as stressful and unnecessary.

Driving forces should exceed restraining forces during movement, the second phase of the planned change process. The initiator of tl1e change, tl1e change agent, should recognize that change takes time, should be accomplished gradually, and should be thoughtfully and comprehensively planned before implementation.

During tl1e refreezing phase, stabilization occurs. If stabilization is successful, the change is assimilated into the system. Change disrupts tl1e comfort of the status quo; it leads to disequilibrium. Therefore, resistance to change should always be antici- pated and expected.

Kotter (1995) expanded Lewin's theory by devising a more detailed eight-step approach for implementing change that correlates to the unfreezing, movement, and refreezing phases in Lewin's model. Kotter analyzed common mistakes made when managers attempt to initiate a change. Based on these mistakes, Kotter's Eight-Step Plan for Implementing Change was devised. The eight steps include:

1. Create a sense of urgency for the change. 2. Form coalitions to have enough power to lead the change. 3. Create a new vision to direct the change; strategies must be developed to

achieve the new vision. 4. Communicate the new vision purposefully and effectively throughout tl1e

organization. 5. Remove barriers to change, empower others to act on the new vision, en-

courage an atmosphere of creativity and risk taking. 6. Plan rewards for short-term "wins" when the organization begins to move

toward the new vision.

394 Unit Ill Shared Theories Used by Nurses

7. Continually assess the effects of the change and make adjustments as neces- sary 111 new programs.

8. Reinfo rce the changes by linking new behaviors to organizational success (Robbins & Judge, 201 5).

Link to Practice 17- 1 illustrates an example of o ne workplace's successful use of Kotter's Eight-Step Plan for Implementing Change.

U ncertain and dynamic environments often characterize the environments of organizations today. In this environment, stability and predictabili ty rarely exist . Dis- ruptions in the status quo are the norm. Organizations today face constant change, often bordering on chaos. Leaders in today's environments of continual change must be prepared to efficiently and effectively adapt to change and must be able to manage all aspects of change-from botl1 external and internal forces.

Most of tl1e time, drivers or the impetus for change originate because of pressure or factors external to organizations. The organization attempts to adjust or redesign tl1e internal environment in attempt to respond to outside factors driving ilie change. Exam- ples of external factors driving change in healili care organjzations today include evolving

Link to Practice 17- l It has been estimated that over 70% of patient care errors occur because of lack of ade- quate communication during transitions in care between one provider and another, that is, during handoffs . Benefits of nursing bedside handoffs have been widely reported in the literature. This article reports on the efforts of one surgical orthopedic trauma unit in adopting a successful change of shift report process after attempting to make the change unsuccessfully several times before.

Kotter's Eight-Step Change Model was util ized to guide the process change. In the first step, a sense of urgency was created by illustrating risk for harm to patients as a result of miscommunication during poor handoff. During the second step, a diverse coa- lition of nurses committed to making the change was formed . Steps 3 and 4 involved cre- ating the vision for the new process and communicating the change to all stakeholders. In this example, staff meetings and educational sessions were scheduled to communicate the vision . During step 5, empowering others to actualize the vision , staff members were instrumental in developing a new process for handoffs which created a sense of owner- ship. In the new process, it was determined it was safer for patients who were sleeping during handoffs to be awakened so that they could be involved . Identifying quick wins, step 6 , reinforced the impetus for the change. A quick win in this example is staff were more likely to be able to leave on time at the end of shift times as a result of efficiencies generated with the new handoff process. Steps 7, build on the change, and 8, institu- tionalize the change, involved integrating and sustaining the change on the unit. Nurse satisfaction was measured postimplementation ; almost 90% of the unit nurses agreed that conferencing with their patients prior to the start of the shift left them with a greater sense of satisfaction . The nurses also strongly agreed that incorporating bedside handoff improved the overall efficiency of the unit and, most importantly, played a significant role in reducing potential and actual errors in patient care.

Small , A. , G ist, D., Souza , D., Dalton, J. , Magny-Normilus, C. , & David , D. (20 16). Using Kotter's change model for implementing beside handoff: A qual ity improvement project. Journal of Nursing Care Qualify, 3 1 (4), 304-309.