Lifestyle-related Health Behaviour Change The Nurses Role

Dr Nicola J Davies

Health Psychology Consultancy, 12 Hitchin Lane, Clifton, Shefford, Bedfordshire, SG17 5RS

www. healthpsychologyconsultancy. co. uk

07866 189276

Keywords: Health; Lifestyle; Behaviour Change

Lifestyle-related Health Behaviour Change

Despite being avoidable, lifestyle-related health issues is of huge personal and financial burden. Lifestyle is notoriously difficult to change for a number of psychological, biological, and environmental reasons.

Current policy advice identifies a key role for nurses in assisting people to adopt and sustain better lifestyle-related behaviours.

Nurses' efforts to promote healthy life styles can be facilitated by the adoption of evidence-based techniques gained from health behavior change ideas.

Motivational interviewing skills may be used to assess patient motivation and readiness to change a health-related behaviour so that interventions can be individually tailored.

Goal-setting and other techniques used to build up patient assurance through mastery and skills development can facilitate the initiation and maintenance of healthy behaviours.

A collaborative relationship between nurse and patient is one of the most efficacious ways of approaching behaviour change in clinical practice.

INTRODUCTION

In an unbiased report offering advice on allowing effective delivery of health and well-being in Great britain, Bernstein, Cosford, and Williams (2010) advise that placing clear priorities for health insurance and well-being should focus on behavioural risk factors. Specifically, they recommend tackling the biggest lifestyle influences on populace health: tobacco, alcohol, physical inactivity and poor diet. These four lifestyle factors are among the largest contributors to many avoidable diseases, across all public groups and in every areas of Britain. They are responsible for 42% of deaths from leading triggers and along they account for at least 9. 4 billion in twelve-monthly direct costs to the NHS (DH, 2009). Low physical activity is the most common chronic disease risk factor, with 95% of the adult society not get together the physical exercise suggestions of at least 30-minutes a day of moderate level exercise five or even more times of the week (Troiano et al. , 2008). Stimulating healthy behaviours in relation to diet, exercise, smoking, and alcohol consumption, is likely to improve individual health insurance and quality of life by lowering the occurrence of lifestyle-related disease. Current policy guidance identifies an integral role for nurses and other frontline personnel in helping people to adopt and maintain a wholesome lifestyle (RCN, 2007). Furthermore, information suggests that patients would prefer lifestyle interventions to be delivered by nurses instead of doctors (Locke, 2004). This post describes a few of the most effective, evidence-based behaviour change techniques that nurses can utilise used. First, the affects of health behaviour will be specified, accompanied by a explanation of some of the key ideas within the field of health-related behavior change.

THEORIES OF HEALTH-RELATED Behavior CHANGE

There is accumulating evidence regarding the cognitive, mental and environmental factors that affect health-related behavior (Table 1). Because of this, medical researchers are being prompted to focus on patients' behaviour and values in their efforts to improve health-related behavior.

TABLE 1. FACTORS INFLUENCING LIFESTYLE-RELATED HEALTH BEAHVIOURS

Attitudes

Beliefs

Motivation

Intention

Volition

Planning

Social support

Self-monitoring

Social and material environment

People's views or judgements with regards to their health.

People's ideas or convictions in relation to their health.

The process that drives health behaviours.

A plan of action intended to have an effect on one's health.

The act of earning a mindful choice in relation to health.

To form specific aims and objectives with regards to health.

The psychical and mental assistance of important people.

The potential to assess and assess one's health.

The modification of factors and affects in the environment that provides about a health gain.

The factors influencing health behaviours are best illustrated within the five theoretical models represented in assignments funded by the Country wide Institute of Health (NIH): Sociable Cognitive Theory, Transtheoretical Model, Motivational Interviewing, Self-Determination Theory, and Public Ecological Theory (Desk 2).

TABLE 2. BEHAVIOUR CHANGE Ideas AND MODELS

Transtheoretical Model (Stages of Change) (Prochaska, DiClemente, and Norcross, 1992)

Behaviour change depends upon readiness to change, which includes five distinct stages:

Pre-contemplation: not yet acknowledging an detrimental behaviour.

Contemplation: acknowledging the poor behaviour, but not yet prepared to change.

Preparation: on the point of change.

Action: changing the unhealthy behaviour.

Maintenance: remaining abstinent.

Social Cognitive Theory (Bandura et al. , 1989)

Behaviour change is determined by a mixture of personal and environmental influences, including observational learning, capacity, final result expectancy (a belief that behaviour change will achieve success), self-efficacy (a opinion that a person is capable of behaviour change), and positive encouragement for attempts to change.

Self-Determination Theory (Deci and Ryan, 1985)

The patient's encounters of autonomy, competence, and relatedness (your time and effort made to relate with others and become concerned to them; sense accepted by others and experiencing satisfaction with the public world) are afflicted by autonomy-supportive health care environments, individual variations in personality, and the intrinsic and extrinsic nature of the patient's goals and dreams. When humans feel their internal needs are being supported, they tend to have better mental health, higher standard of living, and better health-related benefits, such as higher intake of fruits and vegetables, reductions in smoking, increases in physical exercise, and improved upon adherence to healthcare advice.

Social Ecological Theory (Bronfenbrenner, 1994)

The concept of a health-promoting environment whereby behavior is described as some levels, where each part has a resulting impact on the next level. The inner level represents the average person, which is then ornamented by differing levels of environmental influences. For instance, the public environment of family, friends and office are embedded within the physical environment of community facilities, which is subsequently inlayed within the plan environment of different levels of governing physiques. All levels of the social-ecological model effect on the behavior of the individual.

Motivational Interviewing (Miller and Rollnick, 2002)

Motivational interviewing is a person-centred, directive way for enhancing intrinsic motivation to improve by checking out and resolving any behavior change ambivalence. The strategy is underpinned by the belief that the individual is the expert in their own lives and that people are usually better persuaded by their own known reasons for behaviour change than by the reasons of others.

There is accumulating research that behavior change interventions based on these five ideas can succeed in changing health-related behavior. It has also been proven that acquisition of a theoretical understanding of behavior change techniques can enhance the likelihood of medical researchers achieving success in behavior change marketing communications with patients (Powell and Thurston, 2008). Indeed, extensive work within the field of health psychology has led to the identification of the specific behaviour change techniques and strategies that can be used to help people adopt healthier standards of living. This research has been utilised in the Country wide Centre for Smoking Cessation and Training programme (NCSCT, 2010), that was designed to provide evidence-based competencies probably to provide effective effects for smoking cessation. With lifestyle staying a key concern within the government's agenda, there's a need to ensure that medical providers, including nurses, contain the competencies required to deliver brief behavior change interventions.

COMMUNICATING PATIENT-CENTRED CARE

Good verbal and behavioural communication between patient and doctor is important to behaviour change efforts and patient final results. Indeed, studies show that patient-centred health care is associated with better adherence to behaviour change (Robinson et al. , 2008). Key communication skills in patient-centred health care include ascertaining known reasons for accessing medical service, finding common earth, providing information, and sharing decisions. Furthermore, research workers have discovered a list of verbal and non-verbal behaviours that are associated with favourable patient results in terms of behavior change (Figure 1).

FIGURE 1. PATIENT-CENTRED COMMUNICATION SKILLS FOR Behavior CHANGE (Beck, Daughtridge, and Sloane, 2002).

Empathy

Reassurance and support

Encouragement

Explanations

Addressing the feelings and emotions of patients

Increased time on health education

Friendliness

Listening behaviour

Summarisation

Positive reinforcement

Receptivity to patient questions and statements

Allowing the patients point of view to guide the chat in the concluding part of the consultation

In comparison, unaggressive acceptance, formal behaviour, antagonism and passive rejection, high rates of biomedical questioning, interruptions, irritation, dominance, and a one-way stream of information from patient (i. e. information collection without reviews) have all been associated with negative patient final results.

Healthcare specialists have been found to be poor at micro-skills, such as asking wide open directive questions like "How do you feel about. . ?" (Parle, 1997). Generally, health professionals dread that asking available questions to be able to promote behavior change will 'open a can of worms' and lead to emotional reactions that they are unable to deal with, such as depressive disorder, fear, or hostility. Health professionals are also found to find it difficult to speak in challenging situations, like when a patient is in denial.

Other reason that nurses and other health professionals might avoid proposal in behaviour change techniques is a scarcity of time. This problem is likely to become even more dominant due to an increase in medical utilisation during economically difficult times. Notably, nurses will apply behaviour change techniques, such as requesting patients about their diet, compared to allied health professionals (Laws and regulations et al. , 2008). However, when obstacles are present, knowledge of theory and evidence-based instruction can be used to facilitate communication and provide nurses with a realistic benchmark to measure the effectiveness with their communication skills in promoting behavior change.

OPERATIONALISING THEORY INTO PRACTICE

Motivational Interviewing

Motivational interviewing offers a non-confrontational way of boosting the topic of lifestyle with patients, thus conquering at least one of the barriers to such connections. Motivational interviewing is a speedily utilised way that improves the grade of the nurse-patient conversation. In motivational interviewing, emphasis is placed on two key areas of patients' speech, which can be used to guide attempts to help the patient; these are 'Change Discussion' and 'Resistance. ' Change have a discussion can be found via verbal alerts indicative of your desire and determination to improve. Most resistance talk, on the other hand, is an oppositional reaction to behaviour change discussions.

Health baseline comparisons (HBCs), which were theorised as influencing health-related behaviours, give a valuable starting point for exploring people's lifestyle-related behaviour and beliefs (Davies et al. , 2008). HBCs will be the reference point followed by people when they are assessing their health position and thus determining whether any changes have to be made. They are not always successful of healthy lifestyle alternatives such as when, for example, someone who smokes evaluates their health as good because they eat five bits of fruit every day. In such an encounter, nurses may use motivational interviewing ways to guide patients towards a more realistic evaluation with their health position.

Motivational interviewing is a technique that requires steadiness in several center communication skills and is frequently delivered with the aid of several tools and strategies (Table 3). It really is collaborative for the reason that the health professional works with and alongside the patient, dealing with their concerns and assisting them make improvement towards their goals. In addition, it boosts patient autonomy with medical professional left over mindful that the patient is the productive decision machine. The strategy is underpinned by way of a belief that the patient is the expert in their own lives and that individuals are usually better persuaded by their own reasons than that of others.

TABLE 3. MOTIVATIONAL INTERVIEWING SKILLS AND STRATEGIES

Key Skills

Key Communication Skills

Tools and Strategies

Express empathy

Develop discrepancy

Role with resistance

Support self-efficacy

Resist the righting reflex

Understand the patient's dilemma

Listen to the patient

Empower the patient

OARS:

Open-ended questions

Affirmations

Reflective being attentive statements

Summaries to communicate understanding

Setting the scene

Agreeing on the agenda

Exploring a typical day

Assessing confidence

Exploring two possible futures

Looking back and looking forward

Exploring options

Agreeing goals

Agreeing to a plan

Autonomy in decision-making is crucial for the maintenance of new, better behaviours. Many health behaviour change interventions fail because they immediately target behaviour as opposed to the underlying attitudes that drive behaviour. However, by assessing motivation to change and creating those whose frame of mind is conductive of change, nurses can allocate their time and resources correctly. If a patient is motivated to change, then they may only require information and a support system. If they are not motivated to improve, the use of motivational interviewing might either instantly change their attitude or provide them with food for thought that will lead to a future change.

The patient who walks away with no commitment to change need not be perceived as a failed try out. By creating their readiness to improve and their drive to improve, the nurse, by adopting a motivational interviewing way has identified the most efficacious course of action. Sometimes the best plan of action is to simply accept the patients fix to continue with unhealthy lifestyle alternatives, in the knowledge you have at the minimum increased their health literacy in order to make up to date lifestyle decisions.

The utility of this approach is recognized further within the Transtheoretical Model of behavior change, which is defined next.

Readiness to Change

The Transtheoretical model, perhaps better known as the 'periods of change' model, purports that individuals modify their behavior through some five distinct stages (Prochaska, DiClemente, and Norcross 1992):

Stage 1: Pre-contemplation

Not yet acknowledging an harmful behaviour that needs to be changed.

Stage 2: Contemplation

Acknowledging the poor behaviour, however, not yet sure whether an example may be ready or would like to change.

Stage 3: Preparation

Getting ready to change, perhaps placing a quit date.

Stage 4: Action

Changing the unsafe behaviour.

Stage 5: Maintenance

Remaining abstinent.

Some people undertake the phases of change, but most individuals will relapse and go back to earlier stages. This routine is repeated until behaviour change attempts are successful or unsuccessful.

The ten identified processes of change reported by Prochaska, DiClemente, and Norcross (1992) and which are often integrated into behavior change interventions are shown in Desk 4. Helping romantic relationships, consciousness bringing up, and self-liberation have been found to consistently be the most notable three ranked processes regardless of targeted health behavior (e. g. diet, smoking). Helping romantic relationships and consciousness raising are implicit in the nurse-patient dynamic, and self-liberation is something nurses can help patients with through education and support.

TABLE 4. 12 PROCESSES OF CHANGE

Consciousness raising

Self-reevaluation

Self-liberation

Counterconditioning

Stimulus control

Reinforcement management

Helping relationships

Dramatic relief

Environmental reevaluation

Social liberation

Increasing information about bad behaviour.

Assessing personal feelings about an unsafe behaviour.

Choosing and committing to change.

Replacing unhealthy behaviours with substitutes.

Avoiding stimuli that quick detrimental behaviours.

Self-rewards or rewards from others for making changes.

Being wide open and trusting with a person who cares.

Finding solutions to behaviour change barriers.

Assessing how obstacles influence physical environment.

Increasing opportunity for more healthy behaviours.

Based on the Transtheoretical Model, in order to be effective behavior change interventions need to be designed and customized based on the stage of the individual. For example, action-oriented interventions are improbable to produce successful benefits in people who are in the pre-contemplation level and also have not yet acknowledged the necessity to change.

This model illustrates that if a patient leaves the discussion having relocated from pre-contemplation (i. e. does not recognise a need to change an unhealthy behaviour) to contemplation (i. e. is taking into consideration the need to change an unhealthy behaviour), these are one stage closer to initiating a behavioural change likely to improve their health insurance and standard of living. Thus, the goal for nurses is to provide patients with the info and support needed to facilitate prepared decision-making around health-related behaviours. Indeed, aiding the patient to discover for themselves the necessity to change will finally increase self-motivation and the probability of sustained long-term change.

Self-Efficacy

On establishing a patient is encouraged and prepared to change an harmful behavior, evidence-based techniques can be operationalised to assist them achieve their desired results, whether this be to avoid smoking or even to do more exercise. Of main concern should be the patients' degree of self-efficacy (Bandura et al. , 1989) as this can influence both initiation and maintenance of behaviour change. Self-efficacy refers to confidence in one's capability to attain the desired behaviour change. Evidence shows that individuals high in self-efficacy are definitely more resilient when faced with barriers or relapse. Someone with low self-efficacy, on the other hand, is more likely to stop following a setback.

The most effective method of working towards increased self-efficacy for behaviour change has been found to be goal-setting. For example, in a organized review of physical exercise interventions to boost daily walking activity in cancers survivors (Knols et al. , 2010), a definite difference was found between those interventions that produced significant behaviour change and those that didn't - goal-setting was within the former. Notably, these goals need to be realistic and accessible, as well as placed by the individual, not by the nurse. Nurses can, however, guide the process by promoting achievable goals, such as moderate versus vigorous physical activity or 10-minuties exercise 3 x each day when 20-minutes at once might appear too much. Natural goal-setting is particularly important at the beginning of attempts to change behaviour when failing is much more likely to reduce inspiration.

According to Bandura et al. (1989), self-efficacy can be enhanced in four ways:

Mastery: success boosts self-efficacy, failure reduces it.

Vicarious experience: when folks see someone being successful at something, their self-efficacy increase, but when they see people failing, their self-efficacy will reduce.

Verbal persuasion: positive reviews raises self-efficacy and negative opinions decreases it.

Physiological responses: subjective perceptions of physiological responses can transform self-efficacy (e. g. breathlessness after exercise can be interpreted as an indicator of an good work out or an indicator of being detrimental).

Whilst goal-setting has been found to increase self-efficacy via the development of mastery, other evidence-based techniques are also advocated (Ashford and French, in press):

Action planning (i. e. helping the patient invest in a night out when they'll initiate behaviour change; supporting them preparing beforehand for potential obstacles to change, etc. )

Reinforcing effort or improvement towards behavior (i. e. praising or stimulating behaviour change attempts)

Instruction (i. e. demonstrating how a piece of exercise equipment can be used, and providing guidance on how to make more healthily, etc. ).

These strategies can be mixed so a patient is helped to create a realistic goal that can be achieved with a written action plan that includes a time limit, education, and the addition of a reward system. It's important that goals are measurable, so that it is clear when a goal has been achieved. An example of a measurable goal is to achieve 20-minutes of walking 3-times per week. Initiatives to do this goal could be rewarded with words of encouragement, whilst actually achieving the goal could be self-rewarded with, for example, a fresh dress or meals out with friends.

THE 5 A'S FRAMEWORK

A useful way of keeping in mind the order in which to use behaviour change strategies is to look at the 5 A's procedure (Elford, 2000). The 5 A's - Asses; Advise; Agree; Assist; Arrange - have been suggested by the Canadian job make on preventative health care as being the precious metal standard model for behavioural counselling. It really is believed that specialized medical interventions focusing on any lifestyle-related behavior can be defined with regards to these five components.

The first stage is to examine the patients' awareness of any unhealthy behaviours, as well as their determination and readiness to improve. Advice and information may then be provided on the precise hazards and benefits associated with a specific health behavior as well as any support services open to help the patient. After the patient has been totally informed, nurses could work collaboratively with them to agree a set of achievable, measurable goals. Assistance can be provided in conditions of skills development, barrier id, problem-solving, and public support, tending to facilitate the achievements of goals. Planning follow-up with the individual provides the opportunity to conduct a re-assessment as well as to monitor progress and adapt any action projects accordingly. This might be through face-to-face sessions, telephone calls or other forms of contact. Systematic, usual evaluation also allows interventions to be designed as the individual changes and presents with differing needs. Throughout all levels, motivational interviewing skills can be employed as a method of engaging the patient with open-ended questions successful of improving patient autonomy whilst also increasing desire.

CONCLUSION

Research suggests that long-term behaviour change is improbable to be suffered without the active engagement of health professionals. By taking a pastime in a patient's lifestyle and engaging them in behavior change communication, nurses are endorsing a healthy lifestyle, boosting patient health insurance and well-being, and taking primary and secondary preventative measures. This facilitates the Chronic Care and attention Model (Wagner, 1998), which has been extensively found in the redesign of most important care systems. Matching to the model, the fundamental element of good care for folks with persistent conditions is a profitable interaction between health professional and patient. To deliver quality outcomes, for patients and healthcare services, frontline staff need to work towards creating informed turned on patients who have goals and a plan to improve their health. Nurses are well placed to provide this eye-sight through information provision, support, and a wealth of evidence-based health-related behaviour change techniques (Table 5).

Lifestyle-related Health Behaviour Change The Nurses Role

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