Alligood and Tomey (2010) list the assumptions of the Health Promotion Model in this way: 1) Persons seek

to create conditions of living through which they can express their unique human health potential. 2) Persons have the capacity for reflective self-awareness, including assessment of their own competencies. 3) Persons value growth in directions viewed as positive and attempt to achieve a personally acceptable balance between change and stability. 4) Individuals seek to actively regulate their own behavior. 5) Individuals in all their biopsychosocial complexity interact with the environment, progressively transforming the environment and being transformed over time. 6) Health professionals constitute a part of the interpersonal environment, which exerts influence on persons throughout their life spans. 7) Self-initiated reconfiguration of person-environment interactive patterns is essential to behavior change (pp. 441). Again, Penders desire to focus on positive aspects can be seen in her assumptions. She assumes that patients value positive change and that they are capable of self-awareness and self-assessment. In evaluating these assumptions, one must implicitly assume that the patient has the mental and physical capacities to actively decide on their health behaviors. Severe mental disabilities or injury may prevent the patient, who wants to participate in healthy behaviors, from doing so. In addition to developing theoretical assumptions, the nurse theorist must also develop the concepts of his or her theory. Concepts are formulated for both the large scale nursing metaparadigm and also for the specific theory. Pender defines the metaparadigm concept of person as a biopsychosocial entity that is shaped by the environment, but who also seeks to create its own environment where it can express its full potential. Its relationship with the environment is reciprocal. The environment is the context, whether that be social, cultural, or physical, in which the life course takes place. It can be altered so that the person may be able to more readily participate in health promoting behaviors. Health is defined as the person realizing inherent and acquired potential through their goal directed behavior in the areas of self-care, social relationships, and body integrity. Finally, nursing is defined by Pender as working in partnership with the patients, their families, and communities to create a positive and supporting environment in which the patient can express their full potential and perform health promoting behaviors (N. Pender, personal communication, September 14, 2011). As one continues to study Penders Health Promotion Model, a circular pattern of conceptual relationships begin to appear. As one concept is influenced either positively or negatively, it begins a domino effect that alters the following concepts. For example, activityrelated affect is directly related to self-efficacy. A positive affect will increase self-efficacy, whereas a negative affect will decrease self-efficacy. From there, perceived self-efficacy is inversely related to perceived barriers to action. As the patients self-efficacy increases, the number of barriers decreases. As perceived barriers to action decrease, the commitment to perform a health action increases. This cause and effect configuration continues through most of the concepts (Figure 1).

Nola Pender's Health Promotion Model is considered a middle range theory. Middle range theories, are considered more operationalized and more thoroughly evaluated through research

than grand theories. The function of a middle range theory is to describe, explain, or predict phenomena, and must be explicit and testable in order that they may be able to be applied to practice situations and as a framework for research studies. (McEwen and Wills, 2007). Pender's Health Promotion Model is a middle range nursing theory derived from a behavior theory understood as a social learning theory and expectancy-value theory. Pender's HPM, proposed as a framework for integrating nursing and behavioral science perspectives on factors influencing health behaviors, is to be used as a guide to explore the biopsychosocial processes motivating individuals to engage in behaviors directed toward health enhancement (Pender, 1996). This model has been used extensively as the basis for research guided toward predicting health promoting lifestyles along with specific behaviors. A CINAHL search conducted in late 2004 produced listings for 148 English language articles reporting using or applying Pender's HPM during the last ten years. While some studies have used Pender's work as one component of a conceptual framework for their study, others use health promotion as an outcome, and still others have used the HPM to predict behaviors (McEwen & Wills, 2007).

Pender's concepts and the relationships between them are easy to understand. It is reasonable to believe that people wish to be in a state of optimal well-being and independence. The relationships between concepts are also logical. When one is provided with the needed support and obstacles are removed, the likelihood of goal attainment is increased. Pender's definitions of concepts and their relationships remain consistent throughout the use of her theory.

The Health Promotion Model has been tested with patient populations across the lifespan including adolescents, working adults, and older adults in the community. Its ability to be used with a vast array of patient groups in numerous setttings has made it well liked in the nursing community. As the focus of nursing shifts from disease management to disease prevention/health promotion, Pender's model proves to be very useful and relevant (Alligood & Tomey, 2010). The simplicity of this model, with only 10 easy-to-understand concepts, is also seen as a positive. The circular relationship of the concepts (see Figure 1) is easy to follow and logical in its progression. The concepts are abstract enough that it can be applied to many situations, yet not so abstract that the nurse following the model is lost and has difficulty applying it to his or her own practice. The nurse caring for the well patient can use this model to continue to keep the patient in a state of optimal health. The nurse caring for the sick patient may use this model to move that patient towards an increased state of health and wellness. However, this model is focused on particular individuals and is not easily generalizable to groups or community populations.