Theories and Models for

community health nursing

 Under Supervision
Prof .Dr / Awatef Abdelrazek
Head Of Community Health Nursing Department

Prepared By
Amal Abdalla Ahmed
Out lines:
*Difference between theory and model
*Major theories and models in community health
nursing
 Nightingale’s( theory of environment)
 Orem’s (Self-care model)
 Health belief model
 Community nursing practice model
 COMB model
Introduction:
Nursing theory provides an overview: who is the
client and when nursing is needed, and to identify
the boundaries andgoals of nursing’s therapeutic
activities.
Theory is fundamental to effective nursing practice
and research. Effective nursing practice is
facilitated when nurses use a systematic approach
toclients, their health status, and nursing
interventions needed to promote, maintain, or
restore health
Difference between Theory and Model:
A description used as pattern to enhance :*Model
.our understanding of something that is known

*Purpose: to explain a complex reality in a

.systematic manner
A nursing model is a collection of interrelated
concepts that provides direction for nursing
practice, research and education.
 *Theory: set of systematically interrelated
concepts or hypotheses; explain or predict
phenomena ( Barnum,1988 )

In nursing, theory is used to explain a relationship

between observed behaviors and their effects of
.human’s health
*Purpose: to make nursing actions meaningful and
maintain nursing practice as unique as a
professional discipline
Nightingale Theory
Introduction
Theory and practice are two sides of a coin in other words are
reciprocal ends of nursing profession [1]. In fact, clinical Nursing
practice derived light from theoretical foundation. Practice without
integrating nursing theory is blind. Temple of theoretical wisdom
direct nursing practice and research in right way [2]. Clinical
nursing practice itself is the single most authentic platform to test
the theory [1]
My selected theory for clinical application is the pioneer theory of
modern nursing profession. selected theory of Florence nightingale
will be applied to clinical scenario along with brief description of
theorist and theory concerned followed by analysis and critique in
reference to established criteria and concluded with practice
outcomes
2.Theorist Background
Florence Nightingale also known as "Lady with the
Lamp" a persuasive and transformative character in
nursing is the founder of modern nursing. She born
in 1820 in Florence Italy. First nurse theorist,
scientist, writer and philosopher of its kind who
base the discipline of nursing on caring with
wholeness and spirituality She explores the basics of
nursing in her famous piece of writing "Notes on
Nursing: What it is, what it is not" (1860) which is
primitive basis of nursing practice and research. Her
philosophy of nursing was her belief that nursing to
her is "calling from God"
 She emerged during Crimean war with her philosophy of nursing
as calling from god. She introduced her theoretical philosophical
concept of holistic approach in the era when medicine was greatly
involved with biological and physical phenomena of health and
disease. Holistic nursing focus on healing of whole person rather
than caring for a separate sphere of person health like
physiological aspect, and nurses are the healing agent who
facilitate mechanism of healing with honor to person’s individual
subjective feelings
Nightingale emphasis spirituality along with physiological
determination of health disease subject, although her ideology of
spirituality was not based on religious grounds rather her focus was
nature and she largely argue the role of environmental alteration in
health and disease process. Her pioneer theory mainly known by
nightingale environmental theory
 Description of Theory
In watching disease, both in private homes and public 
hospitals, the thing which strikes the experienced
observer most forcefully is this, that the symptoms or
the sufferings generally considered to be inevitable
and incident to the disease are very often not
symptoms of the disease at all, but of something quite
different— of the want of fresh air, or light, or of
warmth, or of quiet, or of cleanliness, or of
punctuality and care in the administration of diet
3.Major Assumptions of Nightingale Theory
Major assumptions in nightingale theory as illustrated by
Victoria Fondriest and Joan Osborne in [1994] are that:
health and sickness are governed by natural laws.
Nursing is a distinct field and is not like medicine. It is a
science and also an art. Disease process is not important
for nursing rather nurses concern is with the individual in
the environment. Environment plays important role in
patients’ health. Nurses should manipulate the
surrounding to promote sufferer recovery. Furthermore,
nurses should be skillful, vigilant and confidential, and
their practice should be evidence base.
4.Concepts in Nightingale Theory
Pure air, Pure water, Efficient drainage, Cleanliness, Light,
Noise, Nutrition and food, Variety, Personal cleanliness,
Bed and bedding were major concepts in nightingale
environmental nursing theory.
4.1.Metaparadigm of Nightingale Environmental Theory
4.1.1.Health
According to nightingale was not only absence of ailment
or being well but to be able to use every power that a
person poses
4.1.2.Environment
Regarded by nightingale is that can be
manipulated according to needs to keep
patient in best form for nature to act upon.
Both physical and psychological aspects of
environment are addressed.
4.1.3.Patient (Person)
Is the holistic being in nightingale theory
and is regarded as someone consisting
physical, spiritual, emotional intellectual
and social aspects.
4.1.4.Nursing
According to nightingale was "calling from God". Nurses
assist nature and utilize in favor to heal sufferer [3].
Beside mention description nightingale philosophy
advocate legacy for activism in care. Some author noted
about her favor for feminism and wrote that she was
champion of feminist ideology in care as quoted in
reference [2]
I have an intellectual nature which requires satisfaction
and that would find it in him. I have a passionate nature
which requires satisfaction and that would find it in him. I
have a moral, an active nature which requires
satisfaction and that would not find it in his life
4.2.Analysis Nightingale Nursing Theory
According to reference [1] theories should be analyzed in
systematic structured manner to know either it is ready
enough to shape practice, develop hypothesis or research
question as there is no unquestionable acceptance of
theories in nursing. Analysis of theory is judge on the base
of set criteria including Significance, Internal Consistency,
Parsimony, Testability, Empirical Adequacy, and Pragmatic
Adequacy [6]
4.2.1.Significance
The significance criteria met when theory justify its worthiness
to the disciplined concerned by offering unambiguous
paradigmatic and philosophical underpinning along with
conceptual clarification of metaparadigm and appropriate
antecedent knowledge citation [6].
Nightingale very simply and clearly describe the concept of
environment and its role in disease and health continuum. She
clearly describes the environment and its essential elements;
fresh air, clean water, proper sanitation, cleanness and light. She
considers illness as imbalance in these essential elements and
believe that manipulation in environment makes client prone
for acting of nature [7]. Nightingale was aware of germ theory
and the role of hygiene in infection control. She emphasis on
the proper disposal of excreta
4.2.2.Internal Consistency
In the framework of theory evaluation in reference [6]
mention that internal consistency attained when theorist is
clear in his/her definitions of concept, construct and
composition and congruency should be there in the define
elements of theory. Nightingale kept the base of public
health nurse and her philosophical underpinning
significantly make foundation of modern nursing as distinct
disciplined of health care although her theory main focus
was home care and she focus on house environment at
same time she device a foundation courses of nursing
science at that mainly limited to women being largely
involved in caring at homes thus nightingale work was
congruent in reference to context and contents [1].
4.2.3.Parsimony
Parsimony described by [6] is focus on content and
the criteria of parsimony fulfilled when theorist
explain phenomena of interest clearly in concise
way. Nightingale conceptual contents are free of
jargons and utilized simple language, her story is
her true experience, her theme is accompanied by
demonstration [7]
4.2.4.Testability
Testability comes fourth in the framework devised by
(Fawcett, 2006) to analyze a theory. In a grand nursing
theory like nightingale environmental theory for criteria of
testability met if the research carried out in qualitative and
inductive way, its research methodology is in congruence to
the contents and philosophical stance of the theory, and
the data collection methodology satisfied the essence of
grand theory by showing researcher personal detail
experience of used data collection mechanism [6].
Nightingale define in detailed construct and abstract
concepts of her theory. Her concept of spirituality and
wholeness is well explained in her theory and later on
tested by the theorist and researcher to adopt in approach
to patient care
4.2.5.Empirical Adequacy
Empirical adequacy refers to the consistency
between theoretical statement and empirical
evidence which can be determine from findings of
studies conducted under the direction of that
theory [6].
Main concepts of her theory noise, spirituality and
environment are testable hypothesis, moreover
her empirical work and statistical analysis of
nineteenth century guide the thinking of 21st
century scientist [8]
4.2.6.Pragmatic Adequacy
According to Reference [6] pragmatic adequacy of nursing
theory is concerned with the practical application and it is
determining by the understanding of nurses to use theory
in their clinical practice along with knowledge and
psychomotor skills required to operationalize practically.
Nightingale theory works as basis and is alive in the
foundation of nursing education and practice, and her
philosophy of environment is still playing central role in the
ecosystem of man. Nurses across the world utilized
nightingale theory in nursing education and care of patients
at different clinical settings
5.Application Nightingale Theory to Practice
Scenario:
I was on evening duty in surgical unit a patient was brought to surgical unit through
causality. Patient was Mrs. X with post op colostomy. patient was operated for
intestinal obstruction due to unknown etiology companied by her mother in law
and three children MRS X was a widow her husband was killed in the war turn
northern province of Afghanistan three years back. Patient was extremely pale with
septic wound; colostomy bag was not covered properly rather it was covered by
plastic bag. entire skin of abdomen was red and lacerated on examination she was
febrile with 103f temperature Blood Pressure was 100/70 and pulse was 96/min
weight was 38 kg. lab findings were hemoglobin 8.5 with moderately leukocytosis.
during history taking patient attendant told that they live in a small house patient
room was also shared by 5 children mother in law and two Cattles. patient
economically poor living on less than 1 dollar per day. on previous medical history
there was intestinal infestation they were used to drink water from nearby well.
According to patient attendant
5.1.Application of Nightingale’s Theory to Nursing Care of Mrs. X
Person Mrs. X is in need of nursing care through nature reparative process. my
(Nurse) goal is to promote nature in the process with application of nightingale
theory with nursing process model.
Assessment:
5.1.1.Physical Environment
Nightingale theory suggest assessment of environment through 13 canons:
According to verbal statement of Mrs. X, and her attendant the house where they
live is injurious to Mrs. x health as their room is overcrowded and shared by
domestic castles. They used well water and use nearby field for toileting purpose
which is the worse form of sanitation and most common Couse of contamination of
water which leads to gastro enteric pathology [9]
Currently Mrs. x is lying on bed in surgical unit with a colostomy bag not
appropriately attached rather over tied by a plastic shopping bag. The leakage of
feces contents badly infected the stoma and lacerate the abdominal skin
5.1.2.Nursing Diagnosis
Infection related to the contamination of the wound with feces
Impaired Skin Integrity related to skin contamination with feces
5.1.3.Interventions
It is planed that Mrs. x and her attendant well be fully educate
regarding importance and methods of cleaning drinking water. Proper
disposal for house excreta and source of social aid will be searched
for financial support to Mrs. x in this connection.
Mrs. X Was provided a side room in the unit. Her stoma was cleaned
with antiseptics and colostomy bag was appropriately applied. The
surrounding skin was washed with saline and soothing anti-infective
ointment was applied. A pad (gauze) putted to absorb the flow of
feces Demonstration regarding stoma care and change of bag
provided to patient. Room windows were kept open for ventilation.
Prescribed medication were given
5.2.Psychological Environment
Mrs. X was very much anxious regarding her health and
kids as she is a widow and have financial Burdon as well as
she is feeling little bit concern due to non-national and
therefore have limited approaches to local resources
currently. She has problem to adopt to new life style with
stoma and have difficulty in falling asleep due to fear of
opening bag during sleep time.
5.2.1.Nursing Diagnoses
Anxiety related to fear of isolation from native country and
culture
Disturbed Sleep Pattern related to the fear of the state of
the stoma
5.2.2.Nursing Intervention
Mrs. X was reassured that she will soon adopt to society.
Her special deserving case in financial terms was
forwarded to hospital administration for free treatment
and a non-government organization was contacted to help
her in easing financial burden.
Environmental factors were evaluated to avoid
disturbance in her sleep. Her visitors were informed
regarding importance of rest and sleep in her recovery
they were counselled to minimize rush in sleeping hours
and avoid unnecessary interruption in the room
environment of Mrs. x.
Mrs. X was explained that her stoma bag will not open
during sleep as it is closed mechanically.
5.3.Nutritional Status
Mrs. x was underweight she lost weight significantly in the
last three weeks. Due to fear of colostomy problem she was
afraid of eating as according to her attendant she avoids
eating as after eating she develops empting problem.
5.3.1.Nursing Diagnosis
Imbalanced Nutrition Less Than Body Requirements related
to ignorance against the needs of food.
5.3.2.Interventions
Nutritionist was consulted regarding food menu appropriate for
Mrs. X condition
Adequate nutrition was provided: containing foods rich in nutritious
values and less in gastro enteric troubles.
Client was motivated for eating and reassured not spare food due to
fear of causing trouble.
Beside systematic care given through nursing process under the
influence of nightingale theoretical stance her remaining canon are
related to observation of patient condition and petty management
[10] which focus on continuity of care. In case of Mrs. I observe her
condition critically and after keen observation of case her attendant
was demonstrated and trained regarding colostomy dressing,
cleanness of stoma with antiseptic moisturizing medication, patient
diet need and variety along with observation of skin color near
stoma was explained in detail
6.Contradictions of Nightingale Theory to Current Day Health Care
System
Some beliefs of nightingale are interesting and though I fell would be
contradicted in today's healthcare:
In her concept noise in the theory suggest that patient sleep should
not be disturb at night on any cost, she emphasis oppose
standardization through licensure examination rather focus on moral
characteristics and spirit of working for nurses, she preferred the ideal
nurse as self-sacrificing, distinguished, and an "angel of mercy," as
compared to an educated, skillful professional nurse [2]
Her philosophy of variety suggests changes in walls color and setting
changes [4]
Contradiction: in today health care settings nurses needs to awake
patients for medications, procedures and vital sign recordings.
Without passing license exam practice is not possible [4]
7.Outcomes of Care Plan
Successful attainment of care out comes achieved by
application of nightingale theory to nursing process of
Mrs. X. As patient verbalize Adjustment to
perceived/actual changes, sign of improvement are
evident on skin around stoma, client demonstrate
behavior regarding health promotion and prevention
of skin breakdown complications. Weight is
maintaining and demonstrate progression in weight
gaining. Patient Report increased feeling rested and
sense of wellbeing she also verbalizes better sleep
and rest comparatively and less disturbance.
8.Conclusion
Colostomy is a major surgical condition in which the colon is
surgically incised for removal of ill or damage part the remaining
end is brought to abdominal surface with an orifice for drainage
of gut. The condition required effective nursing care and
Florence nightingale theory is very appropriate for application to
the care of such patients, beside the fact that theory is more
than a century old it is still alive, easy to applicate in the
fundamental undertaking of nursing interventions. Although
nursing science is progressively advancing with higher degree
of learning, research and invention of suitable technology,
nightingale caring model is functional in the era globally
because her philosophy fits to the basics of nursing and basics
remains same.
OREM’S self care
INTRODUCTION
Theorist : Dorothea Orem (1914-2007)
Born 1914 in Baltimore, US
Earned her diploma at Providence Hospital –
Washington, DC
1939 – BSN Ed., Catholic University of America
1945 – MSN Ed., Catholic University of America
She worked as a staff nurse, private duty nurse, nurse
educator and administrator and nurse consultant.
Received honorary Doctor of Science degree in 1976.
Theory was first published in Nursing: Concepts of
Practice in 1971, second in 1980, in 1995, and 2001
MAJOR ASSUMPTIONS
 People should be self-reliant and responsible for their
own care and others in their family needing care
 People are distinct individuals
 Nursing is a form of action – interaction between two
or more persons
 Successfully meeting universal and development self-
care requisites is an important component of primary
care prevention and ill health
 A person’s knowledge of potential health problems is
necessary for promoting self-care behaviors
 Self care and dependent care are behaviors learned
within a socio-cultural context
DEFINITIONS OF DOMAIN CONCEPTS
Nursing – is art, a helping service, and a technology
Actions deliberately selected and performed by nurses to help
individuals or groups under their care to maintain or change
conditions in themselves or their environments
Encompasses the patient’s perspective of health condition ,the
physician’s perspective , and the nursing perspective
Goal of nursing – to render the patient or members of his family
capable of meeting the patient’s self care needs
To maintain a state of health
To regain normal or near normal state of health in the event of
disease or injury
To stabilize ,control ,or minimize the effects of chronic poor health or
disability
Health – health and healthy are terms used to describe
living things …
It is when they are structurally and functionally whole or
sound … wholeness or integrity. .includes that which
makes a person human,…operating in conjunction with
physiological and psychophysiological mechanisms and a
material structure and in relation to and interacting with
other human beings
Environment
environment components are enthronement factors,
enthronement elements, conditions, and developed
environment
Human being – has the capacity to reflect, symbolize and
use symbols
Conceptualized as a total being with universal,
developmental needs and capable of continuous self care
A unity that can function biologically, symbolically and
socially
Nursing client
A human being who has "health related /health derived
limitations that render him incapable of continuous self care
or dependent care or limitations that result in ineffective /
incomplete care.
A human being is the focus of nursing only when a self –care
requisites exceeds self care capabilities
Nursing problem
deficits in universal, developmental, and
health derived or health related conditions
Nursing process
a system to determine (1)why a person is
under care (2)a plan for care ,(3)the
implementation of care
Nursing therapeutics
deliberate, systematic and purposeful action
 OREM’S GENERAL THEORY OF NURSING
 Orem’s general theory of nursing in three
related parts:-
 Theory of self care
 Theory of self care deficit
 Theory of nursing system
A. Theory of Self Care
This theory Includes:
Self care – practice of activities that individual initiates and perform
on their own behalf in maintaining life ,health and well being
Self care agency – is a human ability which is "the ability for
engaging in self care" -conditioned by age developmental state, life
experience sociocultural orientation health and available resources
Therapeutic self care demand – "totality of self care actions to be
performed for some duration in order to meet self care requisites
by using valid methods and related sets of operations and actions"
Self care requisites - action directed towards provision of self care.
3 categories of self care requisites are-
Universal self care requisites
Developmental self care requisites
Health deviation self care requisites
 1. Universal self care requisites
 Associated with life processes and the maintenance of the
integrity of human structure and functioning
 Common to all , ADL
 Identifies these requisites as:
 Maintenance of sufficient intake of air ,water, food
 Provision of care assoc with elimination process
 Balance between activity and rest, between solitude
and social interaction
 Prevention of hazards to human life well being and
 Promotion of human functioning
2. Developmental self care requisites
Associated with developmental processes/ derived from a
condition…. Or associated with an event
E.g. adjusting to a new job
adjusting to body changes
3. Health deviation self care
Required in conditions of illness, injury, or disease .these include:--
Seeking and securing appropriate medical assistance
Being aware of and attending to the effects and results of pathologic
conditions
Effectively carrying out medically prescribed measures
Modifying self concepts in accepting oneself as being in a particular
state of health and in specific forms of health care
Learning to live with effects of pathologic conditions
 B. Theory of self care deficit
 Specifies when nursing is needed
 Nursing is required when an adult (or in the case of a
dependent, the parent) is incapable or limited in the
provision of continuous effective self care. Orem
identifies 5 methods of helping:
 Acting for and doing for others
 Guiding others
 Supporting another
 Providing an environment promoting personal
development in relation to meet future demands
 Teaching another
C. Theory of Nursing Systems
Describes how the patient’s self care needs will be met by the nurse
, the patient, or both
Identifies 3 classifications of nursing system to meet the self care
requisites of the patient:-
Wholly compensatory system
Partly compensatory system
Supportive – educative system
Design and elements of nursing system define
Scope of nursing responsibility in health care situations
General and specific roles of nurses and patients
Reasons for nurses’ relationship with patients and
Orem recognized that specialized technologies are usually developed
by members of the health profession
A technology is systematized information about a process or a
method for affecting some desired result through deliberate
practical endeavor, with or without use of materials or instrument
Categories of technologies
1. Social or interpersonal
Communication adjusted to age, health status
Maintaining interpersonal, intra group or inter
group relations for coordination of efforts
Maintaining therapeutic relationship in light of
psychosocial modes of functioning in health and
disease
Giving human assistance adapted to human needs
,action abilities and limitations
2. Regulatory technologies
Maintaining and promoting life processes
Regulating psycho physiological modes of functioning in health and
disease
Promoting human growth and development
Regulating position and movement in space
OREM’S THEORY AND NURSING PROCESS
Nursing process presents a method to determine the self care deficits
and then to define the roles of person or nurse to meet the self care
demands.
The steps within the approach are considered to be the technical
component of the nursing process.
Orem emphasizes that the technological component "must be
coordinated with interpersonal and social processes within nursing
situations.
Nursing Process Orem’s Nursing Process
Assessment  Diagnosis and prescription; determine why nursing is 
needed. analyze and interpret –make judgment
regarding care
Design of a nursing system and plan for delivery of care 
Production and management of nursing systems 
Step 1-collect data in six areas:-
The person’s health status 
The physician’s perspective of the person’s health 
status
The person’s perspective of his or her health 
The health goals within the context of life history ,life 
style, and health status
The person’s requirements for self care 
The person’s capacity to perform self care 
Assessment  Diagnosis and prescription; determine why nursing is 
needed. analyze and interpret –make judgment
regarding care
Design of a nursing system and plan for delivery of 
care
Production and management of nursing systems 
Step 1-collect data in six areas:-
The person’s health status 
The physician’s perspective of the person’s health 
status
The person’s perspective of his or her health 
The health goals within the context of life history ,life 
style, and health status
The person’s requirements for self care 
The person’s capacity to perform self care 
Nursing diagnosis  Step 2
Plans with scientific  Nurse designs a system that is wholly or partly 

rationale compensatory or supportive-educative.

The 2 actions are:- 
Bringing out a good organization of the 
components of patients’ therapeutic self care
demands
Selection of combination of ways of helping that 

will be effective and efficient in compensating

Maintenan Inadequate P/F contd. Guiding &
ce of alterations directing,
health Inadequate in health teaching
status status Guiding &
Manageme P/F UTI directing,
nt of teaching
disease
process
Adherence to Inadequate teaching
med regimen
P/F ¯
Awareness of Inadequate adherence
potential teaching
problems in self
catheteriza
tion &
OPD RT
Actual
deficit in
awareness
of
OREM’S WORK AND THE CHARACTERISTICS OF A THEORY
Orem's theory
interrelate concepts in such a way as to create a different way of
looking at a particular phenomenon
is logical in nature.
is relatively simple yet generalizable
is basis for hypothesis that can be tested
contribute to and assist in increasing the general body of
knowledge within the discipline through the research
implemented to validate them
can be used by the practitioners to guide and improve their
practice
must be consistent with other validated theories ,laws and
principles
Strengths
Provides a comprehensive base to nursing practice
It has utility for professional nursing in the areas of
nursing practice nursing curricula ,nursing
education administration ,and nursing research
Specifies when nursing is needed
Her self-care approach is contemporary with the
concepts of health promotion and health
maintenance
Limitations
In general system theory a system is viewed as a
single whole thing while Orem defines a system as
a single whole, thing.
Health is often viewed as dynamic and ever
changing.
The theory is illness oriented
RESEARCH ON OREM'S THEORY
Self-care requirements for activity and rest: an Orem
nursing focus
Nursing diagnoses in patients after heart catheterization--
contribution of Orem
Self-care--the contribution of nursing sciences to health
care
Self-care: a foundational science
Orem's self-care deficit nursing theory: its philosophic
foundation and the state of the science
Dorothea E. Orem: thoughts on her theory
Orem's theory in practice. Hospice nursing care
Solving the Orem mystery: an educational strategy
Orem's family evaluation
The COM-B Theory of Change Model
Introduction
Most interventions seek to change the behaviour of individuals and/or
organizations. Yet surprisingly evaluation of interventions has not
made much use of the quite large literature on behaviour change
theories and models. One review of the literature is by Darnton
(2008).

There are exceptions. Bennett’s hierarchy has been used in the

evaluation of education programs (Bennett 1975; Bennett and
Rockwell 1995). The hierarchy includes an imbedded behaviour
change model where by changes in capacity of knowledge, aspirations,
skills and attitudes (KASA) are seen as leading to practice changes.
Steve Montague has used the Bennett hierarchy in a variety of
evaluation settings (Montague 2000; Montague and Valentim 2010;
Montague and Lamers-Bellio 2012).
The COM-B model

In working with the Palladium group, a more recent

behaviour change model was identified that seems even
more intuitive and is specifically aimed at interventions
aimed at changing behaviour. Michie, Stralen and West
(2011) set out a COM-B model of behaviour change:
behaviour (B) occurs as the result of interaction between
three necessary conditions, capabilities (C), opportunities
(O) and motivation (M).
Capability is defined as the individual’s psychological
and physical capacity to engage in the activity
concerned. It includes having the necessary
knowledge and skills. Motivation is defined as all
those brain processes that energize and direct
behaviour, not just goals and conscious decision-
making. It includes habitual processes, emotional
responding, as well as analytical decision-making.
Opportunity is defined as all the factors that lie
outside the individual that make the behaviour
possible or prompt it.
In a recent article (Mayne 2015), I used the NOA (Needs,
Opportunities and Abilities) model of Gatersleben and
Vlek (1998) discussed by Darnton (2008) as a key part of
a useful theory of change model. Darnton’s review of
behaviour change models notes a key aspect, namely
that all of the capacity change elements in the models
are necessary to bring about behaviour change. How the
capacity change elements are organized and grouped
differ among different models, but are essentially
referring to the same set of capacities. The NAO model
argues that needs and opportunities lead to motivation
which when combined with abilities leads to behaviour
change.
Their COM-B systems model is shown in Figure 1.
Note that both capabilities and opportunities can
influence motivation and all three not only bring
about behaviour change but can also be influenced
by the resulting behaviour change, i.e., there is
often a feedback loop from behaviour change to
capacity change. If practice change seen as limited,
then there may be a need for more capacity change
work.
Working with the COM-B model

In working with this COM-B generic

theory of change model, it was not
always clear how to distinguish among
the capacity and behaviour changes and
their associated assumptions. Consider
these in turn:
 Behaviour Changes

 The behaviour changes are the specific practice changes that occur.
These are usually easy to identify and indeed, to measure.

 Behaviour Change Assumptions

 Since, based on the model, capacity change ‘will’ lead to behaviour
change, it is not always clear what the behaviour change
assumptions should be and indeed if any assumptions are needed.
A distinction in part could be that behaviour change often takes
time to become ingrained and seen as worthwhile, and may
involve feedback between the behaviour and capacity change.
Teaching skills is fine, but then putting them into practice takes
time and no doubt some trial and error.
 Possible generic behaviour change assumptions therefore could
include, the need

 Sustained leadership

 Other sustained support
 Resources
 Early successes

 Application of new capacities being not too difficult

 Capacity Changes

 Capacity changes should be the actual changes acquired in
capabilities, opportunities and motivation. These would often
be more of a challenge to measure and to set targets for. There
might be behaviour change research available that could help.

 Of more immediate concern, is understanding exactly what
these terms mean in the COM-B model. Michie et al. (2011)
define the terms as follows:

 “In this ‘behaviour system,’ capability, opportunity, and
motivation interact to generate behaviour that in turn
influences these components …
Capability is defined as the individual’s psychological
and physical capacity to engage in the activity
concerned. It includes having the necessary knowledge
and skills.

Motivation is defined as all those brain processes that

energize and direct behaviour, not just goals and
conscious decision-making. It includes habitual
processes, emotional responding, as well as analytical
decision-making.

Opportunity is defined as all the factors that lie outside

the individual that make the behaviour possible or
prompt it
 Thus,

With regard to capability, we distinguished

between physical and psychological capability
(psychological capability being the capacity to
engage in the necessary thought processes -
comprehension, reasoning et al.).

With opportunity, we distinguished between

physical opportunity afforded by the
environment and social opportunity afforded
by the cultural milieu that dictates the way
that we think about things (e.g., the words and
concepts that make up our language).
With regard to motivation, we distinguished between reflective
processes (involving evaluations and plans) and automatic
processes (involving emotions and impulses that arise from
associative learning and/or innate dispositions).” (p. 4)

Capabilities is the more straightforward component comprising

skills and knowledge, and frequently addressed in interventions
through training and workshops.
Note though how opportunity is defined.
Opportunities include events outside the individual(s)
that make behaviour change possible—including
changes in social norms—or prompt it—such as
incentives or sanctions.

Motivation could include new ways of thinking and

decision-making. Obviously, in many cases, new
opportunities would trigger enhanced motivation.
 Note then that:

 Motivation are internal processes that have changed such as
new realizations, thinking and forms of decision-making,

 Opportunities are external to the individuals and might
include reasonable costs, making the time to learn, changes in
social norms, incentives or penalties.

 Capacity Change Assumptions

 These assumptions need to be the events and conditions that
are needed to bring about the capacity changes. To some
extent, the outputs intending to lead to the capacity change
are precisely those events and conditions, or perhaps more
likely the events.
 Generic capacity change assumptions might be that:

 Training is relevant to the setting

 Outputs are sensible
 Messages are understood
 Enabling environment is supportive
 Social norms are supportive
 Incentives are supportive

 Reach, if not specifically included.
 Further, assumptions for each of changes in capabilities,
motivation and opportunities need to be addressed or
accounted for.

 Reach and Reaction

 Reach and Reaction are the target groups who are
intended to receive the intervention’s outputs and their
initial reaction. In an ex post situation, reach would be
those actually reached which could be different from
who were intended to be reached. The expectation
would be that those reached saw or were involved with
the outputs. The expected reaction is that the
intervention approach and its outputs were positively
received and deemed worth further consideration.
 Reach Assumptions

 The assumptions here are the events and conditions
needed to occur if the outputs delivered are to reach
and be positively received by the reach groups.

 Generic reach assumptions could include such things as

 the targeted audience is well defined and can be
communicated with,

 the approach and outreach is context sensitive, and
 the outputs are seen as acceptable, and worth
considering.

Some examples

I have redone, using the COM-B model, several of the

examples I used in earlier publications. Figure 3 is the
nutrition example I used in Mayne (2015). The changes
are in the Capacity and Behaviour Change Assumptions,
where the COM components of capacity change are
spelled out.
 HBM
The health belief model (HBM) is a social
psychological health behavior change model
developed to explain and predict health-
related behaviors,
 Health belief model
particularly in regard to
the uptake of health services.[1][2] The
HBM was developed in the 1950s by
social psychologists at the U.S. Public
Health Service[2][3] and remains one of the
best known and
 History
One of the first theories of health the HBM was developed in the 1950s by
social psychologists Irwin M. Rosenstock, Godfbehaviorrey M. Hochbaum,
S. Stephen Kegeles, and Howard Leventhal at the U.S. Public Health
Service. At that time, researchers and health practitioners were worried
because few people were getting screened for tuberculosis(TB), even if
mobile X-ray cars went to neighborhoods.] The HBM has been applied to
predict a wide variety of health-related behaviors such as being screened
for the early detection of asymptomatic diseases[2] and receiving
immunizations.[2] More recently, the model has been applied to understand
 History
patients' responses to symptoms of disease,[2] compliance with medical
regimens,[2] lifestyle behaviors (e.g., sexual risk behaviors),[6] and
behaviors related to chronic illnesses,[2] which may require long-term
behavior maintenance in addition to initial behavior change.[2] Amendments
to the model were made as late as 1988 to incorporate emerging evidence
within the field of psychology about the role of self-efficacy in decision-
making and behavior
most widely used theories in health behavior
research.[4][5] The HBM suggests that people's
beliefs about health problems, perceived benefits of
action and barriers to action, and self-efficacy explain
engagement (or lack of engagement) in health-
promoting behavior.[2][3] A stimulus, or cue to action,
must also be present in order to trigger the health-
promoting behavior
 Theoretical constructs
The HBM theoretical constructs originate from theories
in Cognitive Psychology.[7] In early twentieth century, cognitive
theorists believed that reinforcements operated by affecting
expectations rather than by affecting behavior
straightly.[8] Mental processes are severe constitutes of
cognitive theories that are seen as expectancy-value models,
because they propose that behavior is a function of the degree
to which people value a result and their evaluation of the
expectation, that a certain action will lead that result.[9][10] In
terms of the health-related behaviors, the value is avoiding
sickness. The expectation is that a certain health action could
prevent the condition for which people consider they might be
at risk.[7]
 Perceived susceptibility[edit]
Perceived susceptibility refers to subjective assessment of risk of
developing a health problem. The HBM predicts that individuals
who perceive that they are susceptible to a particular health
problem will engage in behaviors to reduce their risk of
developing the health problem.[3] Individuals with low perceived
susceptibility may deny that they are at risk for contracting a
particular illness.[3] Others may acknowledge the possibility that
they could develop the illness, but believe it is
unlikely.[3] Individuals who believe they are at low risk of
developing an illness are more likely to engage in unhealthy, or
risky, behaviors. Individuals who perceive a high risk that they will
be personally affected by a particular health problem are more
likely to engage in behaviors to decrease their risk of developing
the condition.
 Perceived severity
Perceived severity refers to the subjective assessment of the
severity of a health problem and its potential consequencesThe
HBM proposes that individuals who perceive a given health
problem as serious are more likely to engage in behaviors to
prevent the health problem from occurring (or reduce its
severity). Perceived seriousness encompasses beliefs about the
disease itself (e.g., whether it is life-threatening or may cause
disability or pain) as well as broader impacts of the disease on
functioning in work and social roles. For instance, an individual
may perceive that influenza is not medically serious, but if he or
she perceives that there would be serious financial
consequences as a result of being absent from work for several
days, then he or she may perceive influenza to be a particularly
serious condition.
  Perceived benefits

Health-related behaviors are also influenced by the perceived benefits of taking

action.[6] Perceived benefits refer to an individual's assessment of the value or
efficacy of engaging in a health-promoting behavior to decrease risk of
disease.[2] If an individual believes that a particular action will reduce
susceptibility to a health problem or decrease its seriousness, then he or she is
likely to engage in that behavior regardless of objective facts regarding the
effectiveness of the action.[3] For example, individuals who believe that wearing
sunscreen prevents skin cancer are more likely to wear sunscreen than
individuals who believe that wearing sunscreen will not prevent the occurrence
of skin cancer
 Perceived barriers
Health-related behaviors are also a function of perceived barriers to
taking action.] Perceived barriers refer to an individual's assessment of
the obstacles to behavior change.[2] Even if an individual perceives a
health condition as threatening and believes that a particular action will
effectively reduce the threat, barriers may prevent engagement in the
health-promoting behavior. In other words, the perceived benefits must
outweigh the perceived barriers in order for behavior change to occur.
Perceived barriers to taking action include the perceived inconvenience,
expense, danger (e.g., side effects of a medical procedure) and
discomfort (e.g., pain, emotional upset) involved in engaging in the
behavior.[3] For instance, lack of access to affordable health care and the
perception that a flu vaccine shot will cause significant pain may act as
barriers to receiving the flu vaccine. In a study about the breast
and cervical cancer screening among Hispanic women, perceived
barriers, like fear of cancer, embarrassment, fatalistic views of cancer
and language, was proved to impede screening
 Modifying variables

Individual characteristics, including demographic, psychosocial, and

structural variables, can affect perceptions (i.e., perceived seriousness,
susceptibility, benefits, and barriers) of health-related
behaviors.[3] Demographic variables include age, sex, race, ethnicity, and
education, among others.[3][6] Psychosocial variables include personality,
social class, and peer and reference group pressure, among
others.[3] Structural variables include knowledge about a given disease
and prior contact with the disease, among other factors.[3] The HBM
suggests that modifying variables affect health-related behaviors indirectly
by affecting perceived seriousness, susceptibility, benefits, and barriers
 Cues to action

The HBM posits that a cue, or trigger, is necessary for prompting engagement
in health-promoting behaviors. Cues to action can be internal or
external. Physiological cues (e.g., pain, symptoms) are an example of internal
cues to action. External cues include events or information from close
others,[2] the media,[4] or health care providers[2] promoting engagement in
health-related behaviors. Examples of cues to action include a reminder
postcard from a dentist, the illness of a friend or family member, and product
health warning labels. The intensity of cues needed to prompt action varies
between individuals by perceived susceptibility, seriousness, benefits, and
barriers.[3] For example, individuals who believe they are at high risk for a
serious illness and who have an established relationship with a primary care
doctor may be easily persuaded to get screened for the illness after seeing a
public service announcement, whereas individuals who believe they are at low
risk for the same illness and also do not have reliable access to health care
may require more intense external cues in order to get screened
 Self-efficacy
Self-efficacy was added to the four components of the HBM (i.e., perceived
susceptibility, severity, benefits, and barriers) in 1988. Self-efficacy refers to an
individual's perception of his or her competence to successfully perform a
behavior.[6] Self-efficacy was added to the HBM in an attempt to better explain
individual differences in health behaviors.[12] The model was originally developed in
order to explain engagement in one-time health-related behaviors such as being
screened for cancer or receiving an immunization. Eventually, the HBM was applied to
more substantial, long-term behavior change such as diet modification, exercise, and
smoking.[12] Developers of the model recognized that confidence in one's ability to
effect change in outcomes (i.e., self-efficacy) was a key component of health behavior
change. For example, Schmiege et al. found that when dealing with calcium
consumption and weight-bearing exercises, self-efficacy was a more powerful
predictors than beliefs about future negative health outcomes.
Rosenstock et al. argued that self-efficacy could be added to the other HBM
constructs without elaboration of the model's theoretical structure. However, this was
considered short-sighted because related studies indicated that key HBM constructs
have indirect effects on behavior as a result of their effect on perceived control and
intention, which might be regarded as more proximal factors of action.
 Empirical support
The HBM has gained substantial empirical support since its development in
the 1950s. It remains one of the most widely used and well-tested models for
explaining and predicting health-related behavior.[4] A 1984 review of 18
prospective and 28 retrospective studies suggests that the evidence for each
component of the HBMl is strong.[2] The review reports that empirical
support for the HBM is particularly notable given the diverse populations,
health conditions, and health-related behaviors examined and the various
study designs and assessment strategies used to evaluate the model.[2] A
more recent meta-analysis found strong support for perceived benefits and
perceived barriers predicting health-related behaviors, but weak evidence for
the predictive power of perceived seriousness and perceived
susceptibility.[4] The authors of the meta-analysis suggest that examination of
potential moderated and mediated relationships between components of the
model is warranted.[4]
Several studies have provided empirical
support from the chronic illness perspective.
Becker et al. used the model to predict and
explain a mother’s adherence to a diet
prescribed for their obese
children.[15] Cerkoney et al. interviewed insulin-
treated diabetic individuals after diabetic
classes at a community hospital. It empirically
tested the HBM's association with the
compliance levels of persons chronically ill
with diabetes mellitus
Applications
The HBM has been used to develop effective interventions to change
health-related behaviors by targeting various aspects of the model's key
constructs. Interventions based on the HBM may aim to increase
perceived susceptibility to and perceived seriousness of a health
condition by providing education about prevalence and incidence of
disease, individualized estimates of risk, and information about the
consequences of disease (e.g., medical, financial, and social
consequences).[6]
Interventions may also aim to alter the cost-benefit analysis of engaging in
a health-promoting behavior (i.e., increasing perceived benefits and
decreasing perceived barriers) by providing information about the efficacy
of various behaviors to reduce risk of disease, identifying common
perceived barriers, providing incentives to engage in health-promoting
behaviors, and engaging social support or other resources to encourage
health-promoting behaviors.[6] Furthermore, interventions based on the
HBM may provide cues to action to remind and encourage individuals to
engage in health-promoting behaviors.[6] Interventions may also aim to
boost self-efficacy by providing training in specific health-promoting
behaviors, particularly for complex lifestyle changes (e.g., changing diet or
physical activity, adhering to a complicated medication
regimen).[12] Interventions can be aimed at the individual level (i.e.,
working one-on-one with individuals to increase engagement in health-
related behaviors) or the societal level (e.g., through legislation, changes
to the physical environment
Limitations
The HBM attempts to predict health-related behaviors by accounting for
individual differences in beliefs and attitudes.[2] However, it does not
account for other factors that influence health behaviors.[2] For instance,
habitual health-related behaviors (e.g., smoking, seatbelt buckling) may
become relatively independent of conscious health-related decision making
processes.[2] Additionally, individuals engage in some health-related
behaviors for reasons unrelated to health (e.g., exercising for aesthetic
reasons).[2] Environmental factors outside an individual's control may
prevent engagement in desired behaviors.[2] For example, an individual
living in a dangerous neighborhood may be unable to go for a jog outdoors
due to safety concerns. Furthermore, the HBM does not consider the impact
of emotions on health-related behavior.[6] Evidence suggests that fear may
be a key factor in predicting health-related behavior.
 Community Nursing Practice Model
Overview of the Model
The Community Nursing Practice Model (CNPM) described herein
began with, and continues to be a blend of, the ideal and the practical.
The ideal was the commitment to develop and use nursing concepts
to guide nursing practice, education, and scholarship, and of a desire
to develop a nursing practice as an essential component of a nursing
college. The practical was the effort to bring this model to life within
the context and structures of a community existing health care
system. The model reflects the concept of nursing held by the faculty
of nursing, nursing is nurturing the wholeness of persons and environ-
ments through caring, and the mission of the Christine E. Lynn College
of Nursing

(Florida Atlantic University College of Nursing Philosophy and Mission,

1994/2003).
 Foundations of the Model
Essential values that form the basis of the model
are (1) respect for person; (2) persons are caring,
and caring is understood as the essence of nursing;
and (3) persons are whole and always connected
with one another in families and communities.
These essential or transcendent values are always
present in
nursing situations, while other actualizing values
guide practice in certain situations.
The principles of primary health care from the World Health
Organization (1978) are the actualizing values. These additional
con- cepts of the model are (1) access, (2) essential- ity, (3)
community participation, (4) empow- erment, and (5) intersectoral
collaboration. These also guide health care and social service
practice. Concepts of practice that have emerged include
transitional care and enhanc- ing care. The model illuminates these
values and each of the concepts in four interrelated themes: nursing,
person, community, and environment, along with a structure of
inter- connecting services, activities, and communi- ty partnerships
(Parker & Barry, 1999). An inquiry group method has been
designed and is the primary means of ongoing assessment and
evaluation (Parker, Barry, & King, 2000; Ryan, Hawkins, Parker, &
Hawkins, The principles of primary
health care from the World Health Organization (1978) are
the actualizing values. These additional con- cepts of the
model are (1) access, (2) essential- ity, (3) community
participation, (4) empow- erment, and (5) intersectoral
collaboration. These also guide health care and social
service practice. Concepts of practice that have emerged
include transitional care and enhanc- ing care. The model
illuminates these values and each of the concepts in four
interrelated themes: nursing, person, community, and
environment, along with a structure of inter- connecting
services, activities, and communi- ty partnerships (Parker &
Barry, 1999). An inquiry group method has been designed
and is the primary means of ongoing assessment and
evaluation (Parker, Barry, & King, 2000; Ryan, Hawkins,
Parker, & Hawkins,
 Nursing
The unique focus of nursing is nurturing the wholeness of persons and
environments through caring (Florida Atlantic University [FAU],
1994/2003). Nursing practice, educa- tion, and scholarship require
creative integra- tion of multiple ways of knowing and under- standing
through knowledge synthesis within a context of value and meaning.
Nursing knowledge is embedded in the nursing situa- tion, the lived
experience of caring between the nurse and the one receiving care. The
nurse is authentically present for the other, to hear calls for caring and to
create dynamic nursing responses. The school-based commu- nity
wellness centers and satellite sites in the community become places for
persons and families to access nursing and social services where they
are: in homes, work camps, schools, or under trees in a community gath-
ering spot.
Nursing is dynamic and portable; there is no predetermined
nursing and often no predetermined access place (Parker,
1997; Parker & Barry, 1999).
Nursing practice is further described with-
in the context of transitional care and enhanc- ing care.
Transitional care is that in which
clients and families are provided essential health care
while being enrolled in a local insurance plan that will
partially support that care. Over several weeks, clients are
assisted to enroll in long-term forms of health care
insurance and related benefits and are referred to a more
permanent source of health care in the community.
Transitional care, an ideal for nursing and social work
practice, is sometimes not possible owing to immigration
status, a complex and confounding application process, or
other issues of the family.
Enhancing care describes nursing and
 Person
Respect for person is present in all aspects of nursing, with clients,
community members, and colleagues. Respect includes a stance of humility
that the nurse does not know all that can be known about a person and a
situation, acknowledging that the person is the expert in his/her own care
and knowing his/her experi- ence. Respect carries with it an openness to
learn and grow. Values and beliefs of various cultures are reflected in
expressions of respect and caring. The person as whole and connected with
others, not the disease or problem, is the focus of nursing.
Persons are empowered by understanding
choices, how to choose, and how to live daily with choices made. The person
defines what is necessary to well-being and what priorities exist in daily life
of the family. Nursing and social work practice based on practical, sound,
culturally acceptable, and cost-effective meth- ods are necessary for well-
being and whole- ness of persons, families, and communities.
Early on, Swadener and Lubeck’s (1995) work on deconstructing the
discourse of risk was a major influence on practice. “At risk” connotes a
deficiency that needs fixing; a doing to rather than collaborating with.
Thinking about children and families “at promise” instead of “at risk”
inspires an approach to knowing the other as whole and filled with potential.
Respect and caring in nursing require full
participservicesation of persons, families, and com-
munities in assessment, design, and evaluation of. Based on
this concept, an inquiry group method is used for ongoing
appraisal of services. This method is defined as a “route of
knowing” and “a route to other questions.” Each person is a
coparticipant, an expert knower in their experience; the
facilitator is expert knower of the process. The facilitator’s
role is to encourage expressions of knowing so calls for
nursing and guidance for nursing responses can be heard. In
this way, the essen- tial care for persons and families can be
known, and care designed, offered, and evalu- ated (Barry,
1998;
 Community
Community, as understood within the model, was formed from the
classical definition offered by Smith and Maurer (1995) and from Peck’s
existential, relational view (1987). According to Smith and Maurer, a
community is defined by its members and is characterized by shared
val- ues. This expanded notion of community moves away from a locale
as a defining charac- teristic and includes self-defined groups who share
common interests and concerns and who interact with one another.
Community, offered by Peck (1987), is a safe place for members and
ensures the secu- rity of being included and honored. His work focuses
on building community through a web of relationships grounded in
acceptance of individual and cultural differences among faculty and
staff and acceptance of others in the widening circles, including
colleagues within the practice and discipline, other health care
colleagues from varied disciplines, grant funders, and other
collaborators. The notion of a transdisciplinary care is an exemplar of
this approach to community. Another defin- ing characteristic of
community, according to Peck, is willingness to risk and tolerate a cer-
tain lack of structure. The practice guided by the model reflects this in
fostering a creative approach to program development, imple-
mentation, evaluation, and research.
Environment
The notion of environment within this mod- el provides the context for
understanding the wholeness of interconnected lives. The environment, one
of the oldest concepts in nursing described by Nightingale (1859/ 1992), is
not only immediate effects of air, odors, noise, and warmth on the reparative
powers of the patient, but also indicates the social settings that contribute to
health and illness. Another nursing visionary, Lillian Wald, witnessed the
hardships of poverty and disenfranchisement on the residents of the lower
Manhattan immigrant communi- ties. She developed the Henry Street Settle-
ment House to provide a broad range of care that included direct physical
care up to and including finding jobs, housing, and influ- encing the creation
of child labor laws (Barry, 2003). ecocentric approach grounded in the
cosmos. The whole environment, including inanimate elements such as rocks
and minerals, along with animate animals and plants, is assigned an intrinsic
value” (p. 4). This directs