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August 2004


The Motivation Factor

By Keiba L. Shaw, PT, MPT, EdD, MA

Motivation as a concept is often difficult to define, but is frequently used in discussions by health care professionals and staff in regard to physical rehabilitation and exercise.

Health care professionals and family and friends of patients will regularly comment on what they consider to be a lack of motivation or drive in their patient or loved one. Comments may include "he/she is just not motivated to come for therapy today," and "he/she just won't get out of bed." Rehabilitation providers may lament on how to get their patients motivated to exercise or, just as important, how to encourage their patients to adhere to an established exercise program.

It is an implied belief among health care professionals that motivation plays an important role in predicting the outcome of treatment. Those highly motivated are determined to do well in rehabilitation, whereas those who are not as motivated would be determined to be less successful.1 The act of being motivated or inspiring motivation in patients and clients of all ages and genders then becomes a driving force behind providing quality care.

MOTIVATIONAL CONCEPTS
In order to adequately address this concept of motivation, one must agree upon a definition regarding what one considers motivation to be. Definitions have ranged from motivation as an unidimensional concept of an internal drive or force, to one of multidimensional concepts composed of many variables including both extrinsic and/or environmental factors, and internal or intrinsic factors, that determine how individuals will or will not act. One definition of motivation refers to the "forces that initiate, direct, and sustain behavior."2 Another definition states that motivation is "the inner urge that moves or prompts a person to action...motivation comes from within."3

Other definitions have linked motivation to the theoretical concept of self-efficacy, a term coined by Albert Bandura.4 In this definition, an individual's motivation to engage in behavior is dependent upon their perception of their abilities to successfully engage in and complete a behavior or task.4,5 In this context, motivation can be described by the social cognitive theory, which defines human behavior as a triadic, dynamic, and reciprocal interaction of personal factors, behavior, and the environment.4 Based on this theory, an individual's behavior is uniquely determined by each of these three factors, again alluding to the complex interplay of factors that establish an individual's motivation. However, it should be noted that not all these factors interact equally. For some, social influences and their environment may play a more significant role in their level of motivation. For others, personal experiences, feelings, and biological predispositions such as temperament, personality traits, and genetics may play a larger role to further influence behavior. In this sense, Bandura proposed that the beliefs, expectations, and sense of competence that we as individuals share are developed and influenced by social and physical structures within the environment.

Reciprocal determinism, a notion inherent in the social cognitive theory, proposes that individuals act as contributors to their own motivation, behavior, and development, again within the context of interacting influences. It is in this way that individuals engaged in rehabilitation will experience success or failure based in part on their genetic makeup and in part on how we, as health care professionals, set up and influence their environment.

INCREASING SELF-EFFICACY
Self-efficacy, as a determinant of motivation, should be addressed by utilizing strategies that will increase it. It is presumed that increasing self-efficacy will positively influence functional ability.5 Some elements that have been identified in increasing self-efficacy include: role modeling, emotional arousal, realistic goal setting, reduction in negative feedback, verbal persuasion from a voice of authority, verbal encouragement, individualized care, social supports, and a reduction in unpleasant sensations associated with functional activities.6,7

As stated previously, motivation is a complex concept and is influenced by a variety of internal and external factors. It is so complex that researchers in a variety of areas have attempted to examine its components. One avenue where motivation has been studied has been in the sport psychology literature. This literature supports two views of the elderly individual being either more extrinsically or intrinsically motivated. One view suggests that older individuals return to a state of learned helplessness as characterized by their childhood,8 whereas other views have found that the older athletic population had a tendency to be more internally motivated.9 In more recent literature, it has been found that females and older adults tended to show more signs of intrinsic and self-determined forms of extrinsic motivation.10,11 Vallerand and O'Connor12 also found that older females demonstrated more intrinsic and self-determined extrinsic forms of motivation as assessed by the Motivation in the Elderly Scale, which was based on a population of 130 older adults (median age 76.3 years). In addition, it has been noted that the more experienced athlete is less dependent upon extrinsic motivators.13 In another study,14 older competitive athletes were found to be more intrinsically motivated and more motivated to perform in competition in the oldest age categories.

Within this same literature, gender has been indicated as a reason for differences in motivation between older men and women. Females were found to be more intrinsically motivated and demonstrated more self-determined forms of extrinsic motivation and were less amotivated than males.10,11,15 Likewise, Flood and Hellstedt16 found that learning new skills, making friends, and exercise were more important motives for female competitors than male competitors. The findings for the females may be interpreted as evidencing more intrinsic forms of motivation.

In rehabilitation, older adults ranging from 80 to 94 years old identified several factors that contributed positively to motivation while undergoing therapy (physical and occupational). These factors included establishing goals, the use of humor, as well as having a caring, kind, and competent rehabilitation team. Encouragement, personality, and having power within relationships (themselves and health care professionals) were also found to positively influence motivation. Negative influences included domination, responses to domination, and the belief that there was no need for them to be in rehabilitation.3 It is essential for the health care practitioner to take advantage of those factors salient to the older patient in regard to motivation in the rehabilitation setting.

INCREASING MOTIVATION
It is known that individuals will act and perform an activity if they deem that activity important to them. Therefore, to increase motivation, it is essential for health care providers to maximize activities determined to be meaningful and valuable to a particular individual. In addition, minimizing negative factors, such as low self-efficacy, decreased knowledge about their injury or illness, decreased competence, and a sense of powerlessness, is also key to increasing motivation in the elderly population in regard to rehabilitation. These factors, along with the factors that increase self-efficacy, will contribute to increasing motivation in the geriatric patient.

Members of the rehabilitation team should encourage each patient to take the initiative in their rehabilitation. Promotion of engagement and active participation will decrease the feeling of powerlessness that often accompanies aging. This, in conjunction with increasing the elderly patient's sense of competence by having him or her take responsibility for their progress and by having the patient engage in self-challenging, problem-insight behavior, will go a long way in promoting increased motivation. It has been found that increasing the elderly patient's knowledge about rehabilitation issues and injuries, as well as tapping into any prior experience that they may have had in the rehabilitation process, often will encourage the patient to see themselves as "experts" in their own care. Contrary to popular belief, older individuals are often anxious to get back to their way of life. This want or need will often encourage individuals to do whatever is required so as to return to their previous life.

Another factor mentioned by older individuals that helped to increase their motivation was humor. Humor helps to relieve the tension and stress often associated with the rehabilitation process. Of course, the health care professional should always be aware of establishing appropriate rapport and maintaining safe boundaries when incorporating humor into their treatment sessions.

There are some factors that should be employed by health care professionals regardless of a person's age. These include setting small and attainable goals and giving regular feedback about those goals. This will serve to increase the likelihood of successful performances on any given task. In addition, individuals across the lifespan have reported that observing patients who are successfully performing the task(s) or who have been in a similar situation encourages them to succeed in rehabilitation. For the geriatric patient, role modeling of patients of similar age and injury may be enough to spur them into action and increase their participation in the rehabilitation process. It has been suggested that exposing the older adult to videotaped sessions that focus on the positive aspects of rehabilitation by showing the progression from dependence to independence is beneficial.5

It has been my experience that older individuals are appreciative of the attention given to them by those they entrust with their care. Health care professionals need to take note of the role that they play in influencing motivation in these patients. Establishing rapport by getting to know their patients and choosing interventions that are relevant and meaningful to them will go a long way in increasing adherence and motivation to be in therapy. Encouraging patients by giving positive reinforcement for the goals and tasks that they were able to accomplish will stimulate them to continue to achieve other tasks inherent in their rehabilitation.

We, as individuals, are social in nature and having support in the form of other patients, family, and peers may serve as a reward for a job well done or as encouragement to complete activities that are necessary, but which may not be so appealing. Decreasing the perception of pain, discomfort, and fear will help to strengthen self-efficacy and therefore motivation. This is especially significant for the older adult, as fear of decreasing physical abilities and waning mental acuity predisposes them to being more cautious and a little more reluctant in attempting certain activities.

In summary, motivation as a concept, while difficult to define, can be increased in the elderly rehabilitation population by manipulating internal factors such as self-efficacy, initiative, and a sense of self-competence and external factors such as environment. Health care professionals, and in particular rehabilitation staff, have the responsibility for encouraging participation in rehabilitation by reducing negative experiences, increasing rapport, and establishing and maintaining a safe and trusting environment filled with humor and positive support. All of these factors, in conjunction with appropriate goals, will serve to increase motivation in the elderly population and thereby increase the likelihood of success and establishment of an appropriate discharge plan. The resultant increase in motivation will serve to improve overall functional performance and quality of life for these patients.

Keiba L. Shaw, PT, MPT, EdD, MA, is assistant professor of physical therapy at the University of South Florida College of Medicine in Tampa, Fla.

REFERENCES
  1. Maclean N, Pound P. A critical review of the concept of patient motivation in the literature on physical rehabilitation. Soc Sci Med. 2000;50:495-506.
  2. Vallerand RJ, Losier GF. An integrative analysis of intrinsic and extrinsic motivation in sport. J Appl Sport Psychol. 1999;11:142-169.
  3. Resnick B. Motivation in geriatric rehabilitation. Image J Nurs Sch. Spring 1996:41-45.
  4. Bandura A. Self-efficacy toward a unifying theory of behavioral change. Psychol Rev. 1977;84:191-215.
  5. McCloskey R. Functional and self-efficacy changes of patients admitted to a geriatric rehabilitation unit. J Adv Nurs. 2004;46:186-193.
  6. Resnick B. The impact of self-efficacy and outcome expectation on functional status in older adults. Top Geriatr Rehabil. 2002;17(4):1-10.
  7. Uhl T, Harrison A, English T, Rothbauer J. Rehabilitation concerns of the middle aged athlete. Sports Med Arthroscopy Rev. 2003;11(2):155-165.
  8. Phares ET. Locus of Control in Personality. Morristown, NJ: General Learning Press; 1976.
  9. Rotella RJ, Bunker LK. Locus of control and achievement motivation in the active aged (65 years and over). Percept Motor Skills. 1978;46:1043-1046.
  10. Chantal Y, Guay F, Dobreva-Martinova T, Vallerand R. Motivation and elite performance: an exploratory investigation with Bulgarian athletes. Int J Sport Psychol. 1996;27:173-182.
  11. Fortier M, Vallerand R, Briere N, Provencher J. Competitive and recreational sport structures and gender: a test of their relationship with sport motivation. Int J Sport Psychol. 1995;26:24-39.
  12. Vallerand RJ, O'Connor BP. Motivation in the elderly: a theoretical framework and some promising findings. Canadian Psychology. 1989;30(3):538-550.
  13. Harby K. Atlanta's summer olympics: Not just a young person's games. Ivanhoe Broadcast News Inc. 1997;1-3.
  14. Shaw K. Motivation and Psychological Skills in Senior Athletes. Unpublished dissertation. 2001.
  15. Vallerand RJ, Deci EL, Ryan RM. Intrinsic motivation in sport. Exerc Sport Sci Rev. 1987;15:389-425.
  16. Flood SQ, Hellstedt JC. Gender differences in motivation for intercollegiate athletic participation. J Sport Behav. 1991;14(3):159-168.

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