Pender’s Health Promotion Model

Nursing, as a full-fledged and individual medical industry, has its origins in the mid-19th century. Florence Nightingale, who was active in nursing during the Crimean War, laid the foundation for the development of the school of nursing due to her unique theory. Many of the following concepts and models became iconic and acquired the status of grand, but they were difficult to apply in practice (Khoshnood et al., 2018). As a result, middle-range theories emerged, which focused on practical nursing, and Nola Pender’s Health Promotion Model (HPM) became one of them. According to McEwen and Wills (2019), any theory needs to be tested and analyzed to ensure its success. Over the years, Pender’s HPM has been studied, developed, and supplemented (George, 2011). One of the key findings is that the nurse needs to know and understand “the complex biopsychosocial processes that motivate individuals to engage in behaviors directed towards the enhancement of health” (Pender, Murdaugh, and Parsons, 2006, p. 47 as cited by George, 2011). Therefore, behavioral aspects are the basis of this nursing model.

Theory Description


Pender’s model is a concept that is designed to address human behavioral characteristics with an emphasis on positive impacts. This is designed to predict and explain health promotion behaviors in individuals (George, 2011; McEwen & Wills, 2019). Reconfiguring behavioral patterns in a supportive environment is one of the prescriptions of this model, and the involvement of nursing staff is aimed to provide the necessary conditions for care and assistance.


Pender’s HPM is widely considered a middle-range nursing theory due to its application in practice and the level of details, which are favorable to develop research practice in a variety of nursing settings (Khoshnood et al., 2018). McEwen and Wills (2019) confirm this idea and argue that the HPM describes a limited number of approaches and focuses on a patient’s challenges and outcomes. No general and abstract ideas are offered, but at the same time, the model cannot be applied to any care setting, which corresponds to middle-range theories (Rijsord, 2019).


Nola Pender, in addition to nursing, had a background in human growth and development (George, 2011). She was engaged in studying the contributions obtained due to applying the social cognitive theory and expectancy-value theory while developing the concepts that have formed the basis of the HPM (George, 2011). The HPM was developed in 1982 and revised in 1996, and the theory-research-theory strategy was the main research approach (Aqtam & Darawwad, 2018). The nurse sought to develop the framework that described how, why, or why not people participated in health-promoting behaviors (McEwen & Wills, 2019; George, 2011). This, in turn, helped her include the accumulated knowledge into the single theory.

Major Concepts

In cooperation with her colleagues, Pender reviewed many aspects of individuals and their thoughts related to specific behaviors as important concepts in the HPM (Pender et al., 2002). An individual’s characteristics and experiences, behavior-specific thoughts and feelings, and behavioral outcomes have become the basic tools to study and analyze (George, 2011; McEwen & Wills, 2019). Further, six variables were described, which were considered some of the basic concepts of the HPM: perceived benefits of action, perceived barriers to action, perceived self-efficacy, activity-related affect, interpersonal influences, and situational influences (George, 2011). All these concepts helped create the framework of the model.

Major Theoretical Propositions

As the major propositions, in her model, Pender offers to consider an individual’s personal experience. As George (2011) states, the emphasis is on one’s history, desires, challenges, emotions, and some other inner features. The major theoretical propositions that form the HPM are as follows:

  • Historical behaviors influence future behaviors.
  • People are more likely to engage in specific behaviors if they realize and perceive personal benefits.
  • Barriers, even merely perceived, can inhibit actions.
  • If a person believes in one’s ability to take action, they are more likely to take action.
  • If a person experiences positive emotions during actions, the likelihood of engagement in specific behaviors is increased.
  • If important people in a person’s life model, anticipate, and support specific behaviors, the engagement process is more likely.

Major Assumptions

The major assumptions of the HPM are influenced by the social sciences theories that Pender drew from in the development. According to Pender, Murdaugh, and Parsons (2002), these statements are as follows:

  • People want to express their own human health potential.
  • People can reflect on their own self-awareness.
  • People want both growth and a balance between change and stability.
  • People want to regulate their own behavior.
  • People are always being transformed and transforming their environments.
  • Health professionals are part of that environment.
  • Behavior change must be self-initiated.

Context for Use

Pender’s model may be considered a guide to understanding what motivates people to participate in health-promoting behaviors and. In addition, this is a framework for junior medical personnel to engage collaboratively with patients to work towards health promotion (Khoshnood et al., 2018; McEwen & Wills, 2019). Today, the model is utilized in various nursing spheres, including research, education, and practice (Khoshnood et al., 2018). Some researchers highlight that the HPM can be used in any setting since it applies to patients of all ages, and the need to improve health is ubiquitous (McEwen & Wills, 2019). Therefore, the context for use may be distinctive and concern both nurses and the target audience.

Theory Analysis

Definitions of Concepts

The concept of individual characteristics and experiences is further defined as including prior-related behaviors and personal factors. Depending on health-promoting behaviors examined, these concepts can be operationally defined (George, 2011). Behavior-specific cognitions and affects include six more specific concepts defined in the HPM. They can be measured and assessed by nurses in practice for specific health-promoting behaviors examined. The behavioral outcomes concept includes a patient’s commitment to care, competing demands and preferences, and health promotion behaviors, which are theoretically defined. Therefore, the HPM may be characterized by both types of definitions.

Definitions of Statements

The definitions of HPM’s statements can be determined from both theoretical and operational perspectives. According to Aqtam and Darawwad (2018), all the interventions that form the basis of the model are theory-based, which proves its theoretical background. Operationally, the definitions of statements may be interpreted as the steps designed in a logical order to achieve the ultimate care goal. Thus, both theoretical and operational definitions may describe the HPM.

Explicit Linkages

The linkages in the HPM are explicit, and the intersection of behavioral concepts with health indicators is clear and presented in all the assumptions. As George (2011) states, any reference to personal experience is intended to convey specific implications, and the roles of each factor, whether psychological or sociocultural, are significant. Therefore, any concept or assumption of the HPM may be considered narrowly-focused and explicit.

Logical Organization

The theory in question is organized logically, and there are no ambiguous or inconsistent hypotheses. Most assumptions and statements are structured based on general characteristics designed to interpret certain behavioral features and their impact on human health (Aqtam & Darawwad, 2018). As a result, each of the theses has an argument, while the order of all the propositions is of little importance.

The Theory’s Diagram

Pender’s model has a diagram with all the crucial linkages. At the same time, in 2006, the diagram was revised to reflect the changes in the model (George, 2011). In Figure 1, the corresponding variables are given where arrows demonstrate connections between concepts and variables and show how individual characteristics and experiences can influence behavioral outcomes.


The concepts and assumptions in the model are used consistently. In some critical studies, researchers using their background data in similar ways, and individual authors confirm the logical order of all the variables (Khoshnood et al., 2018). Nevertheless, despite the existing order, the mechanism can be partially changed, which will not affect the general nature and influence of the model.

Predicted Outcomes

Although the model base assumes the use of individual patient variables, the outcomes of interventions are predicted rather than stated. Health-promoting behavior is the ultimate goal, but this aim is subjective and relates to every patient individually, including enhanced life quality, better health, and other factors (George, 2011). Therefore, one cannot argue that the results of interventions will always be the same.

Theory Evaluation

Nursing Standards

The model in question meets modern nursing standards by addressing relevant aspects of care. While taking into account the four main nursing metapardigms, the HPM concerns the care environment, health, nursing, and patients themselves (Branch et al., 2016). Therefore, the key principles of providing support to those in need are respected.

Nursing Interventions and Therapeutics

The nature of this theory makes it applicable to primary rather than acute care settings. Working with patients, managing chronic diseases, or providing public health are the frequent tasks of the HPM (George, 2011). Thus, the model is suitable to utilize in common care conditions.

Empirically Tested and Valid Theory

Pender’s model has been tested and researched repeatedly, including through the empirical method. For instance, Kwan Ho et al. (2010) describe the HPM as a theory that allows developing a program of care for patients with diabetes, and health-promoting behavior is viewed through the lens of nurses’ views on barriers and working mechanisms. Another study by Alkhalaileh et al. (2011) concerns promoting healthy behaviors among childbearing women, homeless women, older adults, families with children ages 12-24 months old, clients with HIV/AIDS, and many other categories. The validity is proven through Pender’s model engine, and statistics on the outcome of the intervention are collected. George (2011) argues that, although the HPM involves positive behavior change, this is not always possible to prove validity in research. However, according to Murdaugh et al. (2006), any improvement indicates movement in the right direction.

Use by Nursing Educators, Researchers, or Administrators

The HPM is used not only in a practical environment but also as a subject of study, research, and control by administrators. For instance, Kwan Ho et al. (2010) present this theory as an approach to diabetes education. The gradual research and development of the model led to the emergence of new variables, which was a consequence of changes in 2006. As George (2011) remarks, a number of countries in the world, including the USA, have always researched the features of the HPM. After the revision, it gained even more popularity and became in demand among managers and administrators.

Social Relevance

Promoting health and improving people’s well-being are the ultimate goals of the national development objectives (U. S. Department of Health and Human Services, 2020). In the current context of the COVID-19 pandemic, the use of the HPM can help transform citizens’ behavior and stimulate their interest in being healthy.

Cross-Cultural Relevance

Pender’s model addresses cross-cultural aspects of nursing care through situational and individual factors. Garcia (2016) examines the application of the theory in relation to Hispanic women and notes the relevance of this methodology to understanding the prospects and barriers to accessing health care.

Discipline of Nursing

Nurses can apply this theory in everyday practice and utilize it as an auxiliary assistance tool. Junior medical specialists provide patient care, which is the primary focus of their work, and the use of the HPM encourages continuous interaction with the target audience, which, in turn, trains nursing skills and discipline.

Implications for Nursing

By utilizing the HPM, the four metaparadigms can be addressed, and the assessment of patient behavior in different clinical settings and diagnoses expands the range of nurses’ competencies and professional skills (Branch et al., 2016). As a result, close provider-patient relationships are established, which improves the quality of care.


Pender’s Health Promotion Model addresses patient behavioral nuances as the key drivers of care. One of the key strengths of this theory is an opportunity to apply different factors that influence behavior as tools for analysis and transformation. At the same time, the model is only suitable for primary care settings, which limits its use in acute care units. I would use the HPM in my own practice because it may be applied to a wide variety of patients. The evaluation of behavioral factors provides a comprehensive picture of a specific health issue, and by analyzing a patient’s experience and internal motives, I can form a clear and effective program of intervention based on addressing the major aggravators and causes of health problems.


Alkhalaileh, M. A., Bani Khaled, M. H., Baker, O. G., & Bond, E. A. (2011). Pender’s health promotion model: An integrative literature review. Middle East Journal of Nursing, 5(5), 12-22. Web.

Aqtam, I., & Darawwad, M. (2018). Health promotion model: An integrative literature review. Open Journal of Nursing, 8(07), 485-503. Web.

Branch, C., Deak, H., Hiner, C., & Holzwart, T. (2016). Four nursing metaparadigms. IU South Bend Undergraduate Research Journal, 16, 123-132.

Garcia, D. (2016). Evaluation of 3 behavioral theories for application in health promotion strategies for Hispanic women. Advance in Nursing Science, 39(2), 165-180. Web.

George, J. B. (2011). Nursing theories: The base for professional nursing practice (6th ed.). Pearson.

Khoshnood, Z., Rayyani, M., & Tirgari, B. (2018). Theory analysis for Pender’s health promotion model (HPM) by Barnum’s criteria: A critical perspective. International Journal of Adolescent Medicine and Health, 32(4), 1-10. Web.

Kwan Ho, A. Y., Berggren, I., & Dahlborg-Lyckhage, E. (2010). Diabetes empowerment related to Pender’s Health Promotion Model: A meta-synthesis. Nursing and Health Sciences, 12(2), 259-267. Web.

McEwen, M., & Wills, E. M. (2019). Theoretical basis for nursing (5th ed.). Lippincott Williams & Wilkins.

Murdaugh, C., Parsons, M., & Pender, N. (2006). Health promotion in nursing practice (5th ed.). Prentice Hall.

Pender, N., Murdaugh, C., & Parsons, M. (2002). Health promotion in nursing practice (4th ed.). Prentice Hall.

Rijsord, M. (2019). Middle‐range theories as models: New criteria for analysis and evaluation. Nursing Philosophy, 20(1), e12225. Web.

U. S. Department of Health and Human Services. (2020). Healthy People 2030: Building a healthier future for all. Web.

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