Elements of Change

1. Elements of Change How to Develop a Change Project

2. Helping patients change behavior • Transtheoretical (Stages of Change) Model • Especially useful in addressing: • lifestyle modification for disease prevention • long-term disease management • addictions • “Patient noncompliance” focuses on patient failure

3. Benefits of transtheoretical model • Understand patient readiness to make change • Appreciate barriers to change • Help patients anticipate relapse

4. Why this model was created • Classically health care relied on • The “just do it” approach • Repeated office visits • Record-keeping suggestions • Follow-up telephone calls • Repeated education is not always successful • Becomes frustrating for you and for the patient • Promising an outcome does not guarantee motivation • Patients may nurse as being critical rather than supportive • Relapse is sometimes viewed as a failure • Failure can cause patients to give up

5. Change is not a single event • Some patients are unwilling to change • Behavior change is now seen process of identifiable stages • You can help by taking specific action at each stage • The Stages of Change model shows that a change in behavior occurs gradually • Relapses are inevitable and become part of the process of working toward lifelong change

6. PRECONTEMPLATION STAGE • The patient is not even consider changing • For example, smokers who are “in denial” may not see that the advice applies to them personally • Patients with high cholesterol levels may feel “immune” to the health problems that strike others • Obese patients may have tried • so many times to lose weight • that they have simply given up

7. Precontemplation

8. Nursing actions:Precontemplation stage • Goal: patient will begin thinking about change • “What would have to happen for you to know that this is a problem?” • “What warning signs would let you know that this is a problem?” • “Have you tried to change in the past?”

9. Prochaska and DiClemente’s Stages of Change Model • Client believes that "Ignorance is bliss" • Nurse’s task is to validate lack of readiness • Clarify for the client, “The decision is his” • Encourage re-evaluation of current behavior • Encourage self-exploration, not action • Explain and personalize the risk

10. CONTEMPLATION STAGE • Client is ambivalent about changing • Giving up an enjoyed behavior causes a sense of loss • The client is assessing barriers • Time • Expense • Hassle • Fear • “I know I need to, but …”

11. Contemplation • Client is also weighing benefits of behavior, proposed change • Motivational interviewing may be welcomed

12. Nursing actions:contemplation stage • The Client is ambivalent about change: "Sitting on the fence" • Not considering change within the next month • Validate lack of readiness • Clarify: decision is theirs • Encourage evaluation of pros and cons of behavior change • Identify and promote new, positive outcome expectations

13. Specific questions: contemplation stage • Goal: patient will examine benefits and barriers to change • “Why do you want to change at this time?” • “What were the reasons for not changing?” • “What would keep you from changing at this time?” • “What are the barriers today that keep you from change?” • “What might help you with that aspect?” • “What things (people, programs and behaviors) have helped in the past?” • “What would help you at this time?” • “What do you think you need to learn about changing?”

14. PREPARATION STAGE • The client prepares to make a specific change • He may experiment with small changes • For example, sampling low-fat foods • Switching to a different brand of cigarettes • Decreasing drinking

15. Principles ofpreparation stage • Experimenting with small changes • Cognitive-behavioral therapy

16. Nursing actions:Preparation stage • Encourage "Testing the waters" • Support if client is planning to act within 1month • Identify and assist in problem solving regarding potential obstacles • Help patient identify social support • Verify that patient has underlying skills for behavior change • Encourage small initial step

17. Action stage • The stage we are eager to see clients reach • Any action taken by the client should be praised • It demonstrates the desire for lifestyle change

18. Principles of Action Stage • The client has taken a definitive action toward change • Cognitive-behavioral therapy • 12-Step program

19. “self-efficacy” • A person’s belief in his own competence • The belief that one is capable of performing in a certain manner to attain certain set of goals • Our personalized ideas of self-efficacy affect our social interactions in almost every way • Incorporates concepts of • Self-confidence • Integrity • Validity

20. Nursing actions:Action stage • Assist in practicing new behavior for 3-6 months • Focus on restructuring cues and social support • Bolster self-efficacy for dealing with obstacles • Combat feelings of loss and reiterate long-term benefits

21. MAINTENANCE AND RELAPSE PREVENTION • Requires incorporating the new behavior “over the long haul” • Discouragement over occasional “slips” may halt the change process • Most clients find themselves “recycling” through the stages of change several times before the change becomes truly established

22. Principles of maintenance • Maintaining new behavior over time • Cognitive-behavioral therapy • 12-Step program

23. Nursing actions:Maintenance • Encourage continued commitment to sustaining new behavior • Pay particular attention to time period between change post-6 months to 5 years • Plan for follow-up support • Reinforce internal rewards • Discuss coping with relapse

24. Principles of Relapse stage • Normal part of process of change • Usually feels demoralized

25. Nursing actions:relapse stage • Acknowledge client’s resumption of old behaviors • May have feeling of “falling from grace" • Assist in evaluating triggers for relapse • Reassess motivation and barriers • Help client identify and plan stronger coping strategies

26. Tips for changing bad habits 1. Work on One Habit at a Time Trying to change more than one habit at a time increases the risk of: Overwhelming yourself Changing no habits at all

27. Tips for changing bad habits 2. Create a Plan and Write it Down It is not enough to say to yourself, “I am going too change It’s in our nature to want to do better. Wanting isn’t enough You must make a plan Write it down Be as specific as possible

28. Tips for changing bad habits 3. Refine Your Plan You need to be realistic Put your plan in a drawer for a day or so and come back to it with fresh eyes Look at each sentence and ask yourself, “Really? I can do that?” Research shows: People’s plans are far too optimistic

29. Tips for changing bad habits 4. Make Mini-Plans These are ‘implementation intentions’ How will you change? These are the steps to implementing your plan (This is the nursing process!)

30. Tips for changing bad habits 5. Repeat! Repeat! Repeat! Habits are behaviors that we do over and over again Habits become almost automatic It is time to make your new habit almost automatic The only way to do it is by repeating and repeating

31. Let’s make a deal… • If you want to lose weight • If you want to increase your activity level • If you want to show your “class participation”

32. It Takes 21 Days To Break A Bad Habit • Choose one unhealthy habit you wish to eliminate or change (weight gain) • Or, choose a healthy habit you want to adopt as part of your behavior (exercise) • If it is a habit to eliminate, you may wish to go "cold turkey" or have a gradual tapering off • Now that you have decided which unhealthy habit to eliminate, or new habit to adopt, decide on the date you will begin your behavior change • Give this date a good deal of thought and then write it down • Experts agree that it takes a minimum of 21 days to change a behavior • Last lecture day is December 5

33. Helpful Suggestions • Write down your goal . • List your reasons for changing or eliminating your habit. • Find substitute routines. For example, if you are changing eating habits and you have identified a particularly difficult time of the day when eating habits are poor, create an activity, a new routine for that time. • Recruit helpers for support. Explain to them why you are making this change. Ask for their support. Their support may be needed encouragement. • Be prepared for people who may sabotage your change. Be assertive and tell them what they are doing. • Submit your plan to me.

34. Sustaining Motivation • Each day review your list of reasons for quitting or changing • Create mental pictures of yourself as having already succeeded with your habit change. • Make affirmations, positive self-statements about your habit change. For example, "I am filled with so much health and vitality now that I exercise four times a week." • Reward yourself. Make up a list of self-rewards. Reward yourself verbally. • Remember to take one day at a time. • If you do backslide, don't label yourself as having failed. Get out your list or reasons for quitting or changing and begin again.