Bev Bennett: School of Nursing and Midwifery, University of Sheffield

Bev Bennett: School of Nursing and Midwifery, University of Sheffield

Motivation and its application to patient rehabilitation

Introduction

Motivation is often described as the key to rehabilitation and rehabilitation professionals often believe that it plays an important role in determining patient outcomes (Maclean et al, 2000a). Furthermore, failure in rehabilitation may be ‘blamed’ on a patient’s lack of motivation (Kemp, 1988). However, the concept of motivation is poorly understood by health care professionals and there appears to be no real consensus about how motivation might be defined operationally (Maclean et al, 2000b) As a result, the day-to-day assessment of a patient as either being well motivated, or poorly motivated, remains largely subjective (King & Barrowclough, 1989) although Maclean et al (2000a) emphasise the importance of understanding the concept of motivation and its use in clinical practice.

What is Motivation?

Resnick et al (1998) describe motivation as an inner urge, which moves or prompts a person to action and Guthrie & Harvey (1994) suggest that a motivated patient is often described as “willing to expend effort, not needing undue encouragement and tending not to complain about the rigours of treatment” (p. 236) However, Maclean & Pound (2000) caution that seeing motivation as a purely internal quality of the individual patient, may lead to moralising on behalf of health care staff; judging the patient as somehow lacking. Indeed, Geelen & Soons (1996) suggest that motivation is more to do with “the way in which a patient experiences or interprets their own efforts … the subjective perception and evaluation of one’s own chances of successful rehabilitation” (p.70) and is affected by all sorts of social or external factors. This suggests that there are factors that can positively or negatively affect a person’s motivation and, therefore, may indicate strategies to enhance motivation.

Theories of Motivation

Numerous psychologists have concerned themselves with the question of motivation and theories range from those based on natural, instinctive tendencies and drives, to those based on learned habits (Kemp, 1988). However, few theories have proved to be useful in a practical, therapeutic sense. Nevertheless, in their review of motivation in relation to rehabilitation, Guthrie and Harvey (1994) noted three groups of theories:

Goal-setting theory - the need for specific goals to motivate
Self-efficacy theory – confidence in oneself to bring about desired outcomes
Possible selves theory – the way people think about themselves and their future

To elaborate on these; in goal-setting theory, the setting of specific and challenging goals is seen as the best way of motivating people. The goals should challenge and be optimistic, they should enlist the caregivers’ support and the patient should participate in the setting of goals (Guthrie & Harvey, 1994). Self-efficacy theory concerns the patient’s perception of their own competence and feelings of self-determination: the patient needs confidence in themselves to perform a task and the belief that they can bring about desired outcomes (Guthrie & Harvey, 1994). The theory of ‘possible selves’, proposes that the capacity of a person to respond positively is underpinned by their beliefs about themselves and how they see themselves in the future (Guthrie & Harvey, 1994).

What Motivation is Not

Kemp (1988) attempts to clarify the concept of motivation more clearly and presents a model for better understanding it, thus providing “a rational basis for making more reasoned and practical interventions” (p.41). However, before proceeding to elaborate on this model, Kemp (1988) highlights what motivation is not and exposes myths about motivation:

Firstly, it is a myth that some people are not motivated, although this is often the conclusion when someone does respond as is expected of them. When an individual is described as not motivated, it usually means that they are acting in an expected or particular way, or they go against the norm. An example of this is where an older person may be finding it increasingly difficult to remain independent at home due to arthritis but they may refuse to seek help or receive it. It is not that the person is not motivated to ‘improve’ their condition; their motive may be to stay at home and resist the ‘interference’ of health or social care staff.
Another myth is that motivation can be measured against a norm and in a linear scale, in the same way as weight or height, i.e. Mr X is more motivated than Mr Y. In this way, Mr Y may be considered lazy because he lacks the level of motivation demonstrated by Mr X.
A further myth is that motivation is the same as compliance or obedience, which requires compliance with the desires of someone else. In contrast, motivation comes from within the person. An example may be in the case of a person with a chronic respiratory disorder who refuses the doctor’s instruction to give up smoking. This action does not mean that they are not motivated, but suggests that there are other motivational factors that outweigh the medical advice, e.g. the comfort and pleasure that smoking provides.
Finally, there is the myth that older people are not motivated, whereas it may be that their motive systems are different. Choices may change during the life course and the amount of effort may diminish but they are still motivated. Indeed, in older people, where the overall prevalence of long-term health conditions and functional impairments may be greater, the capacity to overcome and transcend these problems has a great deal to do with motivation.

A Model to Explain Motivation

Kemp (1988) describes motivation as “a planning process based on the assessment of outcomes of action and the decision for a course of action”, a way of “maximising success and minimising failure in threatening situations according to the individual’s expectations” (p.43). Decisions and effort are determined by subjectively assessing the current situation, in relation to present and past abilities. There may also be costs involved in behaving in a particular way and these need to be balanced against the person’s view of the likelihood of achieving success in a task and the value of the outcome (Kemp, 1988). In other words, the chance of success and the value of the outcome must exceed the cost. If someone wants something enough, then they will strive to achieve it but if the risks or costs outweigh the rewards, then they may abandon their efforts.

Expanding on these concepts, Kemp (1988) proposes a model, based on the “dynamic interplay” of four variables. This interplay represents a motive system and is expressed as a simple equation:

M = W x B x R

Where:

‘M’ is motivation: the direction (choice) of behaviour (acting, thinking, feeling) and force (persistence)

‘W’ is wants: what the person wants, desires, wishes or aims for. Wants generally fall into three categories: what a person wants to get, what they want to do and what they want to express.

‘B’ is beliefs: expectations, assumptions, conclusions and thoughts. The most important beliefs occur in the area of what is believed about the situation or task, the individual themselves, or their future. These beliefs may not necessarily be accurate or rational but it is what they believe that is important. If the belief is negative, they may still have wants but believe that they cannot be achieved.

‘R’ is rewards: the reinforcement, payoff, or outcome. Experiences are rewarding if they bring a feeling of success or pleasure and if the behaviour is not rewarded or rewarding, it soon diminishes.

‘C’ is costs: the consequences, risks or price of the behavior. These costs may be physical, such as the effort needed or pain; psychological, such as their effect on self-image or emotions; or social, such as the disapproval or acceptance of others. Like beliefs, costs may not be factual but perceived.

Using this equation, if the top line (numerator) outweighs the bottom line (denominator), then the positive behaviour will occur but if the opposite is the case, then it will not. However, the issue is complicated when, as Kemp (1988) explains, there is more than one motive system competing with an alternative motive system, with different wants, beliefs, rewards or costs. Both motive systems need to be understood.

An example of this might be where Mrs. B wants to lose weight in order to reduce the strain on her hip and knee joints and thus improve her mobility and thus experience of less pain. Two motive systems may be in operation, one supporting the decision to lose weight, the other supporting the decision not to lose weight. These can be expressed as follows:

Motive system 1:

W = wants to lose weight

B = it will improve her mobility

R = less pain, more mobile

C = self-discipline, hunger pangs, denial of favourite foods, risk of failure.

Motive system 2:

W = no particular desire to lose weight

B = too difficult, time-consuming and it won’t stay off

R = continue to eat what she wants

C = pain and immobility, disapproval of others

In this case, the reason why Mrs. B does not lose weight is not because she is unmotivated; it’s just that the factors on the side of not losing weight outweigh those on the side of losing weight. In developing strategies to help motivate patients, Resnick (1991) suggests that two such motivational equations should be set up so that efforts can be directed at reducing costs and increasing rewards.

Sustaining Motivation

Kemp (1988) also draws a distinction between initiating and sustaining motivation. An analogy can be drawn with New Year’s resolutions which are often easy to start but difficult to keep up, possibly because the rewards and costs may not have been realistically assessed. Longer term, it may become more difficult to sustain rewards and minimise costs.

Motivation and Older People

Kemp (1988) and Resnick (1991), caution that in an older person, the costs may be higher due to diminished physical capacity, the fear of failure or not wanting to look bad in front of other people. Furthermore, Kemp (1988) and Resnick (1991) suggest that there are differences in motivation between older and younger people, distinguished by a shift from ‘achievement’ motivation to ‘conservation’ motivation. This implies that older people need outcomes that are immediate, concrete and help to maintain functioning and quality of life. On the other hand, Kemp (1988) suggests that younger people may have goals that are related to work, leisure and education and are, therefore, often encouraged to participate in rehabilitation by an appeal to future goals.

Thus, Kemp (1988) and Resnick (1991) suggest that older people are more present-oriented, concerned with re-establishing home activities, friendships and leisure activities. They may find things more difficult, get discouraged more easily, not initiate behaviours as readily and even avoid activities that they do not believe they can accomplish.

Strategies to Enhance Motivation

In order to assist a person in enhancing their motivation, Kemp (1988) and Resnick (1991) recommend that in general, a motivational framework must be considered and competing motive systems need to be understood. It should be clear whose motives are being considered, the patient’s or the professional’s, and the focus should be on the individual. More specifically, Kemp (1988) suggests that health care professional should, in keeping with the motive equation:

Explore what the patient wants and why they want it, and assist in the establishment of attainable goals
Explore the patient’s beliefs about the situation, themselves and the future
Find out what is important, offering rewards frequently, especially early on, in order to sustain behaviour
Reduce undesired costs by encouraging patients to verbalise their fears and anxieties and by explaining to patients, what may realistically be expected.

Similarly, Geelen & Soons (1996) suggest further strategies that the health care professional should implement in order to enhance patient motivation. They suggest that the professional should:

Know how the patient perceives the situation
Be alert to potential motivational problems
Tune into the patient’s needs for information and education
Be aware that the patient may not be able to take in information
Set short-term, achievable goals
Make the patient an active partner in rehabilitation
Be aware of their concerns
Look out for hidden costs and make them less emotionally demanding

Guthrie & Harvey (1994) suggest prioritizing those “patients whose needs are particularly great and ... develop a strategy to meet them” (p.241). They identify several key characteristics of rehabilitation practice that could be expected to enhance motivation, which include the need to:

Provide information that may reduce a sense of threat and restore a sense of control
Offer choices about simple daily routines as well as major decisions, to enhance self-determination and control
Assist goal-setting to enhance self-esteem
Attend to emotional needs and social anxieties
Discourage over-protection by carers, which might result in lowered self-esteem
Promote hope
Provide role models of people who have been through similar situations

Further suggestion for strategies to enhance motivation are provided by Maclean & Pound (2000), who likewise recommend that the health care professional should:

Have clear and revisable goal-setting, including making the patient feel that their views are valid and welcome
Have an acceptance of the patient’s idiosyncrasies and avoid clashing with the patient’s value system
Have a warm, approachable and competent manner
Remind the patient that goals exist beyond the ward setting.
Avoid placing the responsibility for motivation and recovery solely on the individual patient.

Finally, Resnick (1994) likens motivation to ‘the wheel that moves’, sometimes rolling forwards by its own volition, but more effectively, facilitated by rehabilitation staff through the qualities of competence, caring, humour, kindness and encouragement. Resnick (2002) further developed this model of motivation, as a guide to encourage nurses to comprehensively assess and “explore the many factors that influence motivation in older adults” and thus “implement appropriate interventions to strengthen motivation” (Resnick 2002, p.158). This is very important, given the knowledge that certain staff behaviors can decrease motivation and contribute to feelings of hopelessness and fear (Resnick, 1996). Indeed, Maclean et al (2000a) also caution that certain ways of conceptualising motivation by staff, can have a negative effect on patient care. When motivation is seen as a quality of a patient’s personality and this view is communicated to patients, feelings of self-blame may be generated, which may impact upon recovery and subsequent quality of life (Maclean et al 2000a, 2000b).

Conflicting Perceptions

The risks of subjective assessment of motivation, highlighted by King and Barrowclough (1989), are supported by a research study undertaken by Resnick (1996), wherein a group of older patients identified as ‘unmotivated’ by nursing staff were interviewed. These patients saw the failure of their rehabilitation to lie with the staff who didn’t understand their needs and said that what they needed was encouragement through kindness, humour, the identification of relevant goals and a relationship characterised by partnership, as outlined above (Resnick, 1994). This suggests a discrepancy between how the rehabilitation team viewed the motivation of older people and how the older people perceived their own motivation (Resnick, 1996). According to Resnick (1996, p.41), it would seem that ‘... all patients may be motivated in their own way and in their own time’, thus, indicating a need for professionals to have a broader approach to motivation.

Conclusion

An understanding of concepts of motivation appears to be central to supporting patients through the rehabilitation process, and professionals need to be aware of the potential impact on patients of their own views of motivation. Labeling patients who fail to engage in a rehabilitation programme as lazy or apathetic is unhelpful and fails to recognise the role that professionals play in supporting patients through what is often a long, painful and difficult process. Assessing individuals subjectivly and
identifying those with proactive demeanors as most likely to display
motivation, may disadvantage those quieter, more passive or non-interactive
patients who may, nevertheless, still be willing to engage and participate in
their own rehabilitation (Maclean et al, 2000a).

References & additional reading

Brillhart, B & Johnson, K (1997) Motivation and the Coping Process of Adults with Disabilities: A Qualitative Study. Rehabilitation Nursing, 22(5), 249-256.

Geelen, R & Soons, P (1996) Rehabilitation: an ‘everyday’ motivational model. Patient Education and Counselling, 28, 69-77.

Guthrie, S & Harvey, A (1994) Motivation and its influence on outcome in rehabilitation. Reviews in Clinical Gerontology, 4, 235-243.

Kemp, B (1988) Motivation, rehabilitation, and aging: A conceptual model. Topics in Geriatric Rehabilitation, 3(3), 41-51.

King, P & Barrowclough, C (1989) rating the motivation of elderly patients on a rehabilitation ward. Clinical Rehabilitation, 3, 289-291.

Laviola, Y (2001) Motivation: An Essential Component to Succeed. Rehabilitation Nursing, 26(1), 34-35.

Maclean, N & Pound, P (2000) A critical review of the concept of patient motivation in the literature on physical rehabilitation. Social Science & Medicine, 50, 495-506.

Maclean, N et al (2000a) The Concept of Patient Motivation. A Qualitative Analysis of Stroke Professionals’ Attitudes. Stroke, 33, 444-448.

Maclean, N et al (2000b) Qualitative analysis of stroke patients’ motivation for rehabilitation. British Medical Journal, 321, 1051-1054.

Resnick, B (1991) Geriatric motivation. Clinically Helping the Elderly to Comply. Journal of Gerontological Nursing, 17(5), 17-20.

Resnick, B (1994) The Wheel That Moves. Rehabilitation Nursing, 19(4), 240-241.

Resnick, B (1996) Motivation in Geriatric Rehabilitation. Image-Journal of Nursing Scholarship, 28(1), 41-45.

Resnick, B (1998) Motivating Older Adults to Perform Functional Activities. Journal of Gerontological Nursing, 24(11), 23-30.

Resnick, B et al (1998) Use of the Apathy Evaluation Scale as a Measure of Motivation in Elderly People. Rehabilitation Nursing, 23(3), 141-147.

Resnick, B (1999) Motivation to perform activities of daily living in the institutionalized older adult: can a leopard change its spots? Journal of Advanced Nursing, 29(4), 792-799.

Resnick, B (2002) Geriatric Rehabilitation: The Influence of Efficacy Beliefs and Motivation. Rehabilitation Nursing, 27(4), 152-159.