Jill Watson is an employee of Telecommunication Company and has been working for the company for approximately 7 years. Within the past few years, Jill has organized numerous health-fairs as well as countless health help sessions. She also regularly posted information on the company central bulletin boards about health and well-being. Moreover, she assists in providing screening program for many sick people. The goal of her health promotion is to enhance positive lifestyles and behavioral changes for people. Despite her promotional effort, many people still engage in smoking habits, do not engage in physical exercise, and are still overweight. While health promotion may be essential, however, providing health information is not sufficient to facilitate positive lifestyle or behavioral changes.
The objective of this study is to use the self-determination theory to assist Jill to understand the strategy to facilitate positive behavioral or lifestyles changes among her clients.
Theory is a set of related concept and document that explains or describes phenomena in a systematic method. However, nursing theory can be defined as definitions, concepts, relationships, proposition or assumptions that are derived from nursing models and designed from concepts for the purpose of prescribing, explaining, or predicting. A nursing theory is also being referred as a body of knowledge that nursing professionals use to support their practice. In other word, nursing theory is an organized body of knowledge that assists in explaining phenomena. The middle range theory is a nursing theory that focuses on human reality, human experience as well as number of concepts. In essence, nursing theory is an autonomy that reinforces nursing practice, education and nursing research.
Self-determination Theory and its Relevance to Clinical Scenario
SDT (self-determination theory) focuses on the social environment that influences human values, attitudes, motivations, as well as human behaviors. In essence, the SDT shows that human organisms are inherently active, motivated and develop naturally over time through an integrative process. This development plays a central and critical role in human learning. In essence, the SDT argues that human being requires particular nutriments such as psychological and biological nutriments used in achieving the psychological well-being and health development. However, if the nutriments are lacked, human heath will be impaired resulting in exhibiting less than optimal behavior. (Deci, & Ryan, 2013). The SDT also believes in human motivation that focuses on behaviors that originate from oneself (autonomous behavior) rather than the controlled behavior or behavior being pressured by the interpersonal forces.
In essence, SDT offers a comprehensive approach to study a healthy behavior and is appropriate in a clinical scenario because it assists in optimal human development. Moreover, the SDT assists in understanding the psychological needs that makes human in demonstrating an effective behavior. Thus, the theory assists in understanding the particular nutriments that could assist human to achieve healthy development.
Ryan et al. (2008) argue that the SDT assists in enhancing a greater understanding of the health related behaviors that may be intrinsic motivated or extrinsic motivated since motivation can facilitate a healthy behavior. In essence, motivation is a psychological force that impels an individual towards a specific goal. For example, most of the health related behaviors such as physical activity or quitting smoking are extrinsic motivated. Thus, individuals are to be trained to value such behaviors if a health provider intends to enact such behavior successfully.
Patrick & Williams (2012) in their argument shows that several health behaviors such as physical activity, tobacco abstinence, and nutrition can have effect on health outcomes and STD can assist in understanding healthy behavioral interventions that can be used to make people conduct in healthy related behaviors. Moreover, human behaviors can affect mortality, morbidity rates as well as health care costs. In effect, chronic diseases can develop from behaviors such as poor diet, and physical inactivity.
Thus, “five key lifestyle behaviors (eliminating tobacco exposure, body mass index
(BMI) < 25, engaging in 30 minutes of physical activity or more per day, consuming alcohol in moderation, and eating a healthy diet) reduced coronary events by 62% over
16 years in a cohort of 42,000 U.S. adult men.” (Patrick & Williams, 2012 p 1).
Thus, an individual adopting in two of these lifestyle behaviors will record 27% lower risks in cardiovascular compared to people who do not adopt the lifestyles. Moreover, lifestyle behaviors account for the 40% of the mortality rates in developed countries and contribute to the two third of all cancer cases. Lifestyle behaviors also account for the management of diabetes, obesity, stroke, cardiovascular disease, and heart attacks. Given the importance of lifestyle behaviors, developing a rigorous health behaviors can assist in achieving a prolong quality of life.
2. Evaluation Model (criteria) to critique the SDT
This study uses the RCT (randomized controlled trial) to evaluate the SDT. The rational for using the RCT model is that it eliminates bias in the overall clinical results since the RCT selects people randomly for the clinical experiment. Typically, the RCT is very effective in testing the effectiveness or efficacy of medical interventions and social science research. The RCT divides the experimental population in control and non-control groups where the control groups receive experimental treatments where non-control group receive no treatment. The essence of the RCT is to assess whether the SDT is useful in explaining and facilitating health behavioral changes for the obesity.
In essence, the SDT provides theoretical insights on the reasons some people engage in certain behaviors and motivations involved in self-regulation behaviors. Typically, obesity is notoriously difficult to manage and indulging in physical activity is an effective strategy to manage obesity. Silva, Markland, Minderico, et al. (2008) uses the RCT to evaluate the SDT utility in explaining and facilitating health behavioral change with reference to obesity management. Typically, the RCT assists in enhancing a better understanding of motivations behind carrying out the physical exercise for obese people. Despite the benefits of RCT in enhancing a greater understanding on the strategy that can be used to manage obesity, however, the STD is only useful to manage the obesity for a short period. Based on the outcomes of the evaluation of the RCT model, the STD can only be used to achieve a little weight loss when using the theory for a long period. Patrick et al. (2008) also use RCT model to evaluate the efficacy of the SDT on the intervention on dental hygiene, physical activity, and tobacco dependence. The benefit of using the RCT for the evaluation of the SDT is that the model is considered the most reliable method in conducting experimental research in healthcare because it assists in eliminating bias and causality.
3. Evaluation Results
This section provides the origin of the theory and key concepts associated to the theory. The section also discusses the strengths and limitation of the theory based on the evaluation results.
3a.Origin of SDT, Key Concepts and their Relationships
The STD was developed in 1970s to compare intrinsic and extrinsic motivation. Although, there was a general understanding during the period that the intrinsic motivation dominated human behaviors, however, it was in 1980s that STD was formally accepted as an effective and sound empirical theory. Since 2000s, the STD has been applied in a clinical setting, and Deci & Ryan (2013) point out that “SDT evolved out of research on the effects of extrinsic rewards on intrinsic motivation.” (p 5). For example, college students were being paid for carry out a work on intrinsically interesting puzzles; however, monetary rewards derived from the work undermined the activity’s intrinsic motivation. Deci et al. (2013) further confirm that rewards undermine intrinsic motivation because they do not enhance motivation for subsequently persistence.
The SDT defines motivation as an intention of an individual to engage in a specific behavior. The theory also distinguishes between the intrinsic motivation and extrinsic motivation, where an extrinsic motivation is a kind of behavior to achieve behavioral outcome that is difference from a self-behavior. Thus, the concept extrinsic motivation occurs when people act because they are compelled or pressured to carry out certain behavior. However, the SDT identifies intrinsic motivation as the kind of behavior that people engage in order to derive satisfaction and enjoyment. Although, “intrinsic motivation is linked to greater productivity, creativity, spontaneity, cognitive flexibility, and perseverance, however, most human behaviors are not intrinsically motivated.” (Silva, Markland, Minderico, et al. 2008 pp2-3).
The SDT also divides extrinsic motivation into external regulation, identified regulation, introjected regulation, and integrated regulation. The external regulation shows that people engage in certain behaviors because they will drive rewards or punishment from such behaviors. However, introjected regulation is a moderately controlled motivation leading to ego involvement. The identified regulation reveals the importance of value, goal and regulation. However, integrated regulation reveals coherence between values, goal and regulation.
3b. SDT Innovative Diagram
The fig 1 reveals the three types of SDT motivations that include demotivation, extrinsic motivation and intrinsic motivation. As being revealed in the diagram, the extrinsic motivation is further divided into:
Fig 1: SDT Innovative Diagram
3c. Summarize of Two Research Articles
This study uses two research articles to test the efficacy of SDT and the first article is titled “Facilitating Health Behavior change and its Maintenance: Interventions based on Self-Determination Theory” and written by (Ryan, et al. 2008 p 2). The authors use the self-determination theory to reveal how people’s health outcomes are being affected by their heath behaviors and lifestyle factors that include physical activity, diet, smoking and hygiene. By consequence, maintenance of people’s behaviors requires experience in self-determination, internal values and skills for change.
Ryan, et al. (2008) argue that SDT focuses on concept autonomy where an individual acquires motivation for health related behaviors. In essence, developing a sense of competence and autonomy requires the integration and internalization through sustainable behavior to achieve a better health and well-being. The authors point out that people’s health behaviors are inherently enjoyable activities and not intrinsic motivated. To enact behaviors such as taking medication, increase physical activity and quitting smoking, people should be able to endorse their importance and value for such behaviors. Unfortunately, many people indulge in behaviors labeled as controlled motivation because they will get external rewards from such behaviors or want to comply with social pressures.
The authors identify introjections as other form of controlled motivation where patients receive praise or approval. Ryan et al. (2008) use the field study as an instrument to test the theory, and from the results of the field study, adherence to a long-term medication is related to patients’ substantial autonomy. Maintained weight loss is also linked to internalization treatments goals and treatment autonomy support. In essence, there has been a linkage between internal motivation, treatment outcomes and autonomy support.
Meanwhile, Ryan et al. (2008) distinguish between extrinsic and intrinsic life goals. The intrinsic life goals focus on inherently satisfying goal that includes physical health, personal goal, and generativity. On the other hand, extrinsic life goals focus on having fame, being physically attractive and acquiring wealth. However, extrinsic goals assist an individual to indulge in a lesser healthy and more risky behaviors.
“There have also been some randomized controlled clinical trials testing the efficacy of SDT-based interventions. These include interventions concerning tobacco dependence, physical activity (Fortier, Sweet, O’Sullivan, and dental hygiene” (Ryan et al. 2008 p 4).
The results reveal that the interventions facilitate and improve treatment outcomes.
The second research article is titled “Chapter 20: Self-Determination Theory” (Deci, at al 2013 p 4). The authors use the SDT to differentiate between controlled and autonomous motivation. The authors relate SDT to the concept social psychology that shows how social environments affect people’s attitude. The authors relate the SDT with social psychology, which influences social environments based on values, attitudes, motivations, as well as behaviors. Typically, the SDT assumes that human are intrinsically motivated, inherently active, and oriented towards the development of integrative process. Although, men are not required to learn these qualities because they are naturally inherent in man, however, men are required to operate effectively towards healthy development and human nutriments, however, man will exhibit abnormal behaviors in the absence these nutriments.
The authors discuss the instruments to measure the SDT where “college students were paid for working on intrinsically interesting puzzles and the monetary rewards undermined their intrinsic motivation for the activity.” (Deci, at al 2013 p 5). The experiment and other similar experiments carried out reveal that rewards might not motivate subsequent persistence; however, rewards can undermine the effectiveness of intrinsic motivation.
d. Strengths and Limitations of the SDT
The outcomes of the evaluation model reveal several strengths of the SDT. First, the theory is theoretical sound revealing the motive people indulge in physical exercise and other healthy behaviors. Silva et al. (2008) argue that the theory can assist in designing an appropriate motivation strategy to assist people in implementing appropriate healthy styles such as engaging in physical exercise to reduce weight or obese body. In the contemporary health environments, the number of people with obese bodies is increasing rapidly. Typically, obesity is the major health problems associated with the number of chronic diseases. Obesity is also associated with psychological problems especially for women. In essence, weight loss through physical exercise is an important clinical management strategy for obesity. However, it is difficult to maintain a weight loss for a long period if appropriate motivation is not implemented. Thus, the strength of the theory has assisted in enhancing a greater understanding of motivated behaviors to manage obesity. For example, healthy diet and regular physical exercise can play a greater role in health maintenance.
The evaluation results reveal that the SDT improve the outcome of the people with obesity, however, the SDT may face challenges in enhancing weight loss for a long period if people are extrinsic motivated. Moreover, the results derived from using the RCT for the SDT evaluation contributes to a better understanding on the strategy the motivations can be used for the treatment of obesity. Although, the cumulative evidence of using the SDT for the regular physical activities is recorded, however, only 20% are able to achieve a long lasting weight loss. Nevertheless, the SDT assists in enhancing a greater understanding of motivation for the obesity management.
Motivation is the psychological forces that impel an individual towards conducting in a specific goal. The SDT assists in enhancing a greater understanding about how an intrinsic motivation can assist people to conduct an appropriate health behavior because this kind of motivation makes people to demonstrate an enjoyable behavior. The theory also assists in making people to understand that extrinsic motivation such as external regulation is not appropriate to make people conduct a healthy behavior because external regulation will conduct people into a forced behavior, which may not produce a long-term health benefits. More importantly, the theory assists in enhancing a greater understanding of the concept amotivation, which involves lack of intention to engage in a specific behavior. Thus, the theory will assist a health promoter such as Jill Watson to understand there is a need to apply a specific motivation technique to make people indulging in a healthy behavior.
Other strength of the theory lies in its wide scope because its application cut across various cultures. It also encompasses a wide range of phenomena and cut across various life domains since the theory can be used to internalize the individual goals in order to increase performances. Moreover, the intrinsic motivation assists individuals desired to achieve personal growth as well as achieving self-defined goals. More importantly, the theory assists individuals to seek personal improvement.
Moreover, the SDT can be used for many applications that include medical health, workplace, education culture, family relationships, romantic relationships, mental health, sport and leisure. For example, Niemiec & Ryan (2009) applies the SDT in education and the outcomes show that the theory has supported the student’s satisfaction to achieve autonomy, relatedness and competence. Deci & Ryan (2008) also reviews several studies that apply SDT in sport and exercises. The outcomes show that the theory assists in delivering positive autonomy, performances as well-being for individuals.
Despite the strengths recorded by the theory, however, the limitation of the SDT is that it fails to provide intrinsic impetus for individuals to become personal motivated.
Applicability and Usefulness of the SDT to the Advanced Nursing Practice
Several criteria can be identified in the theory, which can make the SDT applicable to the advanced nursing practice. First, the theory can assist the nursing professionals to understand the strategy to make patients to conduct in certain healthy behaviors. For example, nursing professionals can use the theory to make people desist from smoking tobacco, which is one of the major causes of cancer. Moreover, application of intrinsic motivation can assist nursing professionals to make patients indulging in behavioral outcome to manage the glucose control for diabetes patients. Moreover, the SDT intervention will make nursing professional to understand the strategy to promote health-related behaviors. Using the SDT, nurses will able to understand the strategy to manipulate patients to engage in weight control in order to achieve a long-term weight management.
Deci, E.L. & Ryan, R.M. (2013). Handbook of Theories of Social Psychology: Volume 1 Self-Determination Theory. SAGE Publications Ltd.
Ng, J.Y.Y., Ntoumanis, N., Thogersen-Ntoumani, C. (2012). Self-determination theory applied to health contexts: A meta-analysis. Perspectives on Psychological Science, 7, 325-340.
Niemiec, C.P., & Ryan, R.M. (2009). Autonomy, competence, and relatedness in the classroom: Applying self-determination theory to educational practice. Theory and Research in Education, 7, 133-144
Patrick, H. & Williams, G.C. (2012). Self-determination theory: its application to health behavior and complementarity with motivational interviewing. Int J. Behav Nutr Phys Act. 9: 18.
Ryan, R.M., Patrick, H., Deci, E.L., & Williams, G.C. (2008). Facilitating health behaviour change and its maintenance: Interventions based on self-determination theory. The European Health Psychologist, 10, 2-5.
Silva, M.N. Markland, D. Minderico, C.S. et al. (2008). A Randomized Controlled Trial to Evaluate Self-determination Theory for Exercise Adherence and Weight Control: Rationale and Intervention Description. BMC Public Health. 8: 234.
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