Locus of control theory
Locus of control theory describes the extent to which people believe they are in control of their own health. This theory proposes that people who believe they are in control of their own health status are more likely to change behaviors in response to health information than people who don’t believe they have such control. Individuals who believe or feel that their health is in the hands of God or fate or the physicians (external control) are less likely to take preventive healthy actions. People who feel that they are in charge of their health condition (internal control) are more likely to adopt healthy behaviors. Locus of control theory is especially relevant for patients with limited education and low literacy skills. If they have had difficulty understanding health care instructions, they may feel that managing their own health is beyond their understanding.Nurses can assist patients with an external locus of control by encouraging use of social support systems and by helping them believe they have the ability to control health events and by helping them improve their decision making skills.
Cognitive dissonance theory
The basis of cognitive dissonance theory is that a high level of unhappiness or dissonance is a stimulus for behavioral change. A person’s readiness to change is based on feeling sufficiently unhappy with the present health care status. Most people don’t feel good when they keep doing things they know are unhealthy. For example, a person who is fully aware that smoking is unhealthy and wants to quit would likely suffer some cognitive dissonance (mental discomfort) when realizing he or she is opening the third pack of cigarettes of the day. The basis of cognitive dissonance theory is that people want to reduce discomfort and return to a more comfortable state. Health care professionals using cognitive dissonance theory might deliberately increase the patient’s discomfort about a desired behavior or allow the patient to choose an unhealthy option that increases discomfort. Educational strategies based on cognitive dissonance theory are useful in getting a patient to make a decision to stop an unhealthy behavior or to add a healthy behavior and to maintain the new behavior once the decision has been made. After patients have made a healthy decision, reinforcement is needed to keep them from regressing.
Diffusion theory refers to the observation that some people will try new behaviors more readily than others will.Understanding and using diffusion theory is particularly appropriate when teaching individual patients and family members and when educating a community, as those people who are more willing to adopt change can influence others. The first individuals within a family group or a community to try out and adopt new ideas are innovators who are secure enough to feel comfortable in making a change. These people may serve as models or change agents for others who follow. The next group to adopt the change are known as early adopters. Both innovators and early adopters tend to make decisions based on rational thinking and experiences. To persuade these people to change a health behavior, your message needs to be logical and must include the reason for the change and proof of results.3 Those individuals who are willing to change later-the late adopters-are likely to be more conservative and less secure. Late adopters are motivated more by social influences such as local organizations and friends than by rational thinking. Health information heard at a neighborhood party is likely to have more influence on late adopters than advice from a health expert seen on television. Health care professionals can use diffusion theory to help influence individuals within a group or community. The initial target for the health care message is the innovators and early adopters in the group. These people may be political figures, teachers, or sports figures. When early adopters have made the desired behavior changes, the message may be revised to stress social influences for the desired behaviors.
Stress and coping theory
Coping refers to an individual’s constantly changing cognitive and behavioral efforts to manage specific external or internal demands that the person senses are stressing his or her physical and psychological resources. A person’s coping abilities change over time in response to new situations. Both personal and situational factors influence the amount of stress perceived and coping efforts. Personal factors are those things the individual brings to the situation, such as his or her personal life experiences. Situational factors refer to how the person perceives and interprets each unique situation.
People cope with health care problems in a variety of ways. Some examples include:
- Exercising self-control
- Positive reappraisal
- Finding social support
- Learning problem solving skills
Escape-avoidance is a coping strategy by which a person denies a problem exists. This strategy may work in the short term, but is not a useful long-term coping strategy. Distancing is a strategy in which people separate themselves from the problem and convince themselves that their condition is so unique that they cannot benefit from the experience of others. Another method of coping is exercising self-control. Individuals who use self-control as a coping strategy gain control by participating in self-care and being active in decision making. Positive reappraisal is a coping strategy in which a person focuses on what one can do, rather than dwelling on what can’t be done.
Some people seek social support when they feel they cannot cope effectively on their own. Importantly, there is growing evidence that giving support, i.e., being helpful to others, may be as important as receiving support. Nurses should consider using patients who are more confident and skilled in performing health care tasks to help others as a means of increasing coping by participating in a helper role. Problem solving is one of the most useful strategies available to people to cope with illness. Unfortunately, most patient education programs teach solutions, not problem solving practices. Nurses can have a major impact on helping patients cope with both acute and chronic illness by incorporating more problem solving strategies into patient teaching efforts.
Appraisal-focused coping refers to efforts a person makes to define the meaning of a situation and can take the form of problem-focused coping or emotion-focused coping. When using problem-focused coping, a patient deals with the reality of a situation by modifying the source of the threat or handling the consequences of the problem. A person engaged in emotion-focused coping focuses on managing the emotions aroused by an event.For example, a 58-year-old woman has just been diagnosed with breast cancer. Her first response is emotion-focused coping. She shares her diagnosis with her family and close friends and begins to openly seek emotional support from them. At the same time, she begins to develop some problem-focused coping strategies by obtaining information from the Internet about breast cancer diagnosis and treatment options.
Learning is a process that involves behavior change. Domains or categories of learning help guide and direct teaching and learning. The three learning domains described briefly, are:
- Cognitive domain: knowledge and understanding of facts, concepts, and principles
- Psychomotor domain: physical skills
- Affective domain: attitudes, values, and beliefs
The cognitive domain involves using mental processes to recall, apply, and evaluate facts and information. Cognitive learning involves learning new facts or concepts, and building on or applying past knowledge to new situations. An example of learning in the cognitive domain would be a diabetic patient who is able to state the signs of hypoglycemia and hyperglycemia, or is able to plan an appropriate diet. When teaching a patient factual information, use teaching strategies such as discussion, programmed instruction, written information, videotapes and audiotapes, and computer assisted instruction.
The psychomotor domain involves the physical skills that a person needs to perform a procedure or technique. Psychomotor learning includes the development of manipulative or physical skills, ranging from simple movements to complex actions. A diabetic patient who learns how to operate blood glucose monitoring equipment or to inject insulin is acquiring psychomotor skills. Strategies to help a patient learn psychomotor skills are demonstration and return demonstration and practice drills.
The affective domain involves attitudes, beliefs, and values that influence behavior. Affective learning includes values, religious and spiritual beliefs, family interaction patterns and relationships, and personal attitudes that affect decisions and the problem-solving process. Learning in the affective domain involves a change in attitudes or emotions that will affect behaviors. Discussion, simulations, and role-playing are teaching strategies used to teach in the affective domain. The nurse uses all three domains, depending on what is to be taught. To learn or change a health behavior, the patient may need to learn in all three domains. The nurse’s role is to select a combination of content from the three domains that is appropriate to meet individualized patient teaching goals.