Therapeutic Alliance Model and Model of Health Education In Nursing

Model of Health Education In Nursing and Therapeutic Alliance Model

Therapeutic Alliance Model In Nursing Education,Models for Health Education In Nursing,Similarities and Dissimilarities of Models In Nursing Education.

Therapeutic Alliance Model In Nursing Education

    Barofsky’s (1978) therapeutic alliance model addresses a shift in power from the provider to a learning partnership in which collaboration and negotiation with the consumer are key. A therapeutic alliance is formed between the caregiver and the care receiver in which the participants are viewed as having equal power. 

    The client is viewed as active and responsible, with an outcome expectation of self care. The shift toward self-determination and control over one’s own life is fundamental to this model.

    The therapeutic alliance model compares the components of compliance, adherence, and alliance. According to Barofsky (1978), change is needed in treatment determinants change from coercion in compliance and from conforming in adherence to collaboration in alliance. 

    The power in the relationship between the participants is equalized by alliance. The role of the patient is neither passive nor rebellious but rather active and responsible. The expected outcome is neither compliant dependence nor adherent conformity but responsible self-care resulting from an alliance between the nurse and the patient.

    Although not originally developed as an educational model, the usefulness of this model to the nurse as educator is nevertheless acknowledged in the partnership of learning. This interpersonal model is appropriate in the educational process when shifting the focus from the patient as a passive dependent learner to the patient as an active learner. 

    It serves as a guide to refocus education efforts on collaboration rather than on compliance. The nurse as educator and the patient as learner form an alliance with the goal of self-care.

    Hobden (2006), in a recent exploration of the concepts of compliance and adherence, notes that these terms have a negative connotation. Instead, this author suggests emphasizing the consultative process known as concordance, which is “consultation that allows mutual respect for the patient’s and professional’s beliefs, and allows negotiation to take place about the best course of action for the patient” (p. 258). 

    She notes there is a shift in the balance of power from the professional to the patient. Although concordance should lead to improved health outcomes, the focus is on the process.

    Kim, Boren, and Solem (2001) developed the Kim Alliance Scale (KAS), which was later revised by Kim, Kim, and Boren (2008) as the Kim Alliance Scale Refined (KASR) to measure the quality of the therapeutic alliance between patient and provider. The refined scale includes collaboration, integration, empowerment, and communication subscales. 

    In these authors’ study, the KAS-R was shown to be valid and reliable and, when it was used to measure the relation- ship between therapeutic alliance and general patient satisfaction, therapeutic alliance was a significant predictor variable (36%) for patients’ general satisfaction. The link between therapeutic alliance and patient satisfaction underscores the significance of the quality of the provider patient relationship.

    As mentioned earlier, motivational inter- viewing may be combined with the therapeutic alliance model. Duran (2003) points out that successful MI takes place in an atmosphere in which the client feels understood and respected, and it is collaborative in nature, with the highest priority placed on the client’s autonomy and freedom of choice. 

    The significance of the therapeutic alliance between caregiver and patient as it relates to adherence has been studied in patients with mental health issues (Ardito & Rabellino, 2011: Arnow et al., 2013; Byrne & Deane, 2011; Jaeger, Weißhaupt, Flammer, & Steinert, 2014; Sylvia et al., 2013). 

    Del Re, Flückiger, Horvath, Symonds, and Wampold (2012) found that therapist behavior in the alliance partnership is more important than patient behavior in achieving the goal of improved outcomes. The therapeutic alliance also has been studied relative to weight gain in patients with anorexianervosa (Bourion-Bedes et al., 2013; Brown, Mountford, & Waller, 2013), although its impact has been mixed.

Models for Health Education In Nursing 

    Selection of models for educational use can be made based on the following considerations: 

(1) similarities and dissimilarities

(2) the nurse as educator’s agreement with model conceptualizations

(3) functional utility 

Similarities and Dissimilarities of Models In Nursing Education

    Models may be viewed as so similar that there would be a negligible difference in choosing one over the other, or they may be considered so dissimilar that one would be inappropriate for a specific educational purpose. A cursory comparative analysis of the different frame works reveals that the health belief model and the health promotion model are similar. 

    Each uses comparable salient factors of individual perceptions and competing variables. The differences appear in the models’ basic premises and outcomes. The health belief model emphasizes susceptibility to disease and the likelihood of preventive action, whereas the health promotion model emphasizes health potential and health promoting behaviors.

    The self efficacy theory, the theory of reasoned action, and the theory of planned behavior are similar in that they focus on the predictions or expectations of specific behaviors. These theories lend themselves more easily to less complex model testing than either the health belief model or the health promotion model because the former theories are more linear in conceptualization. Specificity of behaviors may aid in targeting outcomes of educational programs. 

    The stages of change model are similar to self efficacy theory, the theory of reasoned action, and the theory of planned behavior in the sense that these models focus on intent. The stages of change model, though, appears to be less complicated and does not account for personal characteristics or experiences. 

    It differs from self efficacy theory, protection motivation theory, the theory of reasoned action, and the theory of planned behavior in that change is time relevant, which has implications for educational interventions. 

    Protection motivation theory is similar in construct to the theory of reasoned action and the theory of planned behavior in the sense that information is cognitively processed, followed by intent or commitment to action and the health behavior. 

    The health belief model, health promotion model, self efficacy theory, protection motivation theory, theory of reasoned action, and the theory of planned behavior are similar in that they acknowledge factors such as experiences, perceptions, or beliefs relative to the individual and factors external to the individual that can modify health behaviors. 

    These frameworks also recognize the multidimensional nature, complexity, and probability of health behaviors. 

    One major difference between the health belief model and the protection motivation the ory is that the latter includes a component of fear appraisal and focuses on a specific vulner ability rather than general susceptibility to illness (Prentice-Dunn & Rogers, 1986).

    All the models acknowledge the importance of the patient in decision making with respect to health behaviors. The differences. relate to patient focus, the relative importance of modifying factors, specificity of behavior, and outcomes.

    The most dissimilar model is the therapeutic alliance model. Although it is relatively narrow in scope, its simplicity and parsimony are strengths. When this model is applied to the educational arena, the educator learner relationship is the critical factor. 

    Addressing potentially frustrating patient education situations such as noncompliance, Hochbaum (1980) noted that patient educators, when frustrated, “are unable to understand the apparently irrational and self-destructive action of their patients, and sometimes throw their hands up in despair, bedeviled by the seeming irrationality of the patient’s behavior.

    But this behavior may be altogether rational from the patient’s perspective” (p. 7). Understanding of the patient as learner can be uncovered in the therapeutic alliance model.