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

Motivation and its application to 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 patients 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 ones 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 persons 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). Selfefficacy theory concerns the patients 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 doctors 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 individuals 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 persons 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=

WxBxR
C

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 wont 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; its 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 Years 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 patients or the professionals,
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 patients 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 patients 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 selfesteem
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 patients idiosyncrasies and avoid clashing with the
patients 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 patients 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 didnt 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.