COURSE PRICE: $10.00
CONTACT HOURS: 1
Wild Iris Medical Education is an approved provider of continuing education by the American Occupational Therapy Association (AOTA), Provider #3313. Courses are accepted by the NBCOT Certificate Renewal program.
Content Focus
Domain of OT: Context and Environment
OT Process: Outcomes
Professional Issues: Contemporary Issues and Trends
The planners and authors of this CE activity have disclosed no relevant financial relationships with any commercial companies pertaining to this activity.
Persis Mary Hamilton has a rich background in nursing, nursing education, and writing. She has written fourteen nursing textbooks for two major publishers. Her doctoral dissertation investigated the relationship of learning to behavioral objectives and visual design in a textbook. Persis Hamilton works with Wild Iris Medical Education to ensure compliance with American Nurses Credentialing Center accreditation guidelines. She is involved with assessing needs, planning, implementing, and evaluating all nursing continuing education activities offered by the company. Over the years Hamilton has worked in most areas of nursing. She taught for more than 40 years in vocational, associate degree, baccalaureate degree, and graduate nursing programs, served as item writer for the League for Nursing, and was the principle speaker at numerous continuing education workshops. In addition, she has conducted research in Micronesia as well as Guam. Currently, Persis maintains a private practice in psychotherapy. Recently she completed a historical novel about the care of psychiatric patients in the 1930's, entitled Deportation Train.
Copyright © 2007 Wild Iris Medical Education, Inc. All Rights Reserved.
Upon completion of this course, you will be able to:
Healthcare providers are in the business of helping folks who cannot help themselves. They want to cure, to comfort, to prevent illness, and to promote health. When people come asking for help with their problems and their pain, we listen, ask questions, conduct tests, consult with others, make diagnoses, and develop plans of care. To be effective, however, every plan requires some action—some change in behavior on the part of the patient.
Often the action is quick and easy, as when we instruct the person to "Take the prescribed medicine," "Inhale deeply and relax," or "Immobilize that strained muscle."
Sometimes the change is long and difficult, as when you advise the patient to "Learn to live with diabetes," "Stop smoking," or "Move to an assisted-living facility."
Even when a change in behavior is relatively simple, such as taking a pill, people are remarkably resistant to change. In fact, research tells us that two-thirds of Americans fail to take any or all of the medications that are prescribed, no matter the circumstances (AHA, 2002).
Knowing this, if caregivers really want to help people, they must do more than hand folks a prescription and tell them to come back in a month. They must accept the challenge to become change agents, motivating, educating, and supporting patients throughout the process of change. To do this, providers of healthcare need to understand the nature of change, assess the readiness of individuals to change, and communicate in ways that facilitate behavioral change.
Change is movement, alteration, adaptation, and action. It is a process that occurs with or without a particular timetable, expert direction, or even planning. Sometimes change occurs slowly and subtly, sometimes quickly and dramatically, and often, haphazardly. Even when change is planned and specific outcomes are identified, change seldom proceeds in a straight line or at a steady pace, affected as it is by multiple internal and external factors.
Because of its importance in every field of human endeavor, the concept of change has been the subject of study for decades. Early research focused on types of change. Bennis and colleagues identified eight types of change:
Sampson suggested three kinds of change:
Duncan (1978) argued there were only two types of change: haphazard and planned. Note that all of these researchers recognized planned change, that is, change that focuses on a specific, measurable outcome. This is the kind of change healthcare professionals seek to bring about in their patients.
All planned change has an end goal, a specific outcome the planner hopes to achieve. Even so, healthcare providers differ regarding the most effective way to bring it about. Some clinicians take a content-driven approach to planned change, while others follow an outcome-driven approach. Those who take a content-driven approach assume that when individuals receive information about a disorder or a harmful activity they will "see the light," apply the data to their personal situation, and change their behavior.
For example, Jim just learned he has type 2 diabetes. He knows nothing about diabetes and until now has paid little attention to his diet or his health. His physician recognizes the need for Jim to learn about his disease, but knows only a content-driven approach to patient education. He does not think in terms of changing patient behavior or of himself as a change agent.
The doctor gives Jim several pamphlets about diabetes and suggests he attend classes offered by the local hospital. Though Jim reads the brochures, he does not understand the relationship of blood glucose levels to diet, nor does he grasp the seriousness of the red, swollen area on his foot.
A more effective method of bringing about planned change in folks like Jim is the outcome-driven approach. This approach focuses on specific, measurable objectives. Information is personalized and related to specific goals for the patient. For example, when Jim attended the class at the hospital, he realized he needed information as it applied to his problems. He asked the patient educator for help.
The educator consulted with Jim's physician and identified several specific measurable objectives. One of these was "Jim will accurately perform a blood glucose test, 100% of the time." At a private session, the educator explained the reason for the test and its relevance to Jim's disorder and encouraged him to discuss his fear of blood and pain. Then, she demonstrated the procedure and discussed problems that might arise in performing the test.
Jim mirrored the demonstration until he could do it accurately 100% of the time. The patient educator, acting as a change agent, linked the rationale for the test to the disorder and to Jim's diet, further motivating him to change his behavior. Such an outcome-driven approach:
Because change requires action of some type, individuals who come seeking help must be motivated to do something. Recent studies indicate that motivation to change requires both conviction and confidence (Austin, 2006):
Without these two core beliefs, patients are not motivated to take action and make changes. They are more apt to become discouraged, fall back into old behaviors, and give up. With these factors, individuals are motivated to achieve specific objectives.
Three factors interact to influence change—the clinician, the environment, and the patient:
Change occurs in a series of stages or steps. These stages are especially noticeable if the change represents a significant alteration in lifestyle. Prochaska (1994) identified five sequential stages that people experience as they change from old behaviors to new ones. He called these stages (1) pre-contemplation, (2) contemplation, (3) preparation, (4) action, and (5) maintenance.
Precontemplation begins when the person consciously recognizes the need to change a behavior but does not know how to do it. For example, Kathy had smoked cigarettes for more than 25 years. She had tried to stop many times but had never succeeded. In the precontemplative stage she is not happy with her current state, wants to change, but views the task as too difficult, beyond her grasp, and not worth the effort.
Contemplation is the stage when an individual intends to change some behavior relatively soon, say in the next six months. For example, Kathy understands the benefits of change but is afraid of the consequences. Her awareness of the benefits of success and fear of failure produces profound ambivalence and keeps her immobilized, stuck in procrastination. According to Tilton (2007), people in the contemplation stage are not yet ready to change.
Preparation is the stage in which an individual makes up the mind to take action in the immediate future, perhaps next month. Often something has happened to motivate the person to take action, such as an emotion-laden crisis, recent illness, or plea from an important individual in the person's life. In Kathy's case, a surgeon urged her to have an umbilical hernia repair. In preparation for general anesthesia, she must stop smoking. Kathy's conviction of the importance of stopping smoking has increased. Her confidence in her ability to do it is yet to be proved, but she is ready to take action.
Action is the stage in which people actually modify their behavior. They develop new habits and work toward SMART goals. These goals, or objectives, are Specific, Measurable, Attainable, Realistic, and Tangible. During the action stage, people need to remain confident and convinced they can and will change their behavior. Because they are most likely to relapse into old behaviors during the action stage, stage 5 is critical.
Maintenance is the stage in which people work to prevent relapse. They are tempted to go back to their old behaviors and need ongoing support to keep from slipping back into a familiar pattern of living. Such support is enhanced by encouragement from primary care providers, colleagues, friends, and members of self-help groups. Kathy joined such a group and found the suggestions and support of the members a great help as she persisted in maintaining her new image as a nonsmoker.
To bring about behavioral change, healthcare providers need to establish a supportive clinical relationship with each patient. To do this, they show nonjudgmental empathy, listen attentively and reflectively to patient statements, and use both verbal and nonverbal messages. They help the individual achieve specific objectives, take into account the person's stage of change, and assess their level of conviction, degree of confidence, and ambivalence toward change. Finally, caregivers arrange a variety of follow-up measures to encourage patients to maintain the changes they have made.
When an individual comes to a healthcare professional with a problem, the caregiver's first challenge is to establish a relationship of trust. You do this by giving the person your absolute attention. Listen attentively to the patient, seeking to understand not only the facts of the case but also the overall meaning of the problem to the patient.
Health professionals respond appropriately and respectfully, giving nonjudgmental empathy, genuine concern, and unconditional positive regard (Rogers, 1961). As a result, the patient feels understood and truly heard. The healthcare professional might say, "I think I understand how you feel…please tell me more about…."
Another useful technique for building rapport is reflective listening. The goal of such listening is to express interest and to understand what the speaker is saying (Austin, 2006). For example, the clinician asks "How are you doing today?" The patient says "Oh, I guess I'm all right." The clinician notices the glum tone of the voice and the tentative nature of the reply and reflects back, "You seem a bit discouraged. What's going on?" When clinicians reflect back what they see and hear, they demonstrate genuine concern for the patient's welfare and encourage the person to express real feelings to the caregiver.
The verbal and nonverbal messages of clinicians significantly affect the relationship of patients to caregivers. Nonverbal messages, such as leaning toward the patient, nodding, listening intently, and making eye contact, indicate sincerity and builds rapport. The judicious use of silence gives both the clinician and the patient time to consider an issue thoughtfully.
As the interview proceeds, caregivers find certain words more useful than others. For instance, questions that begin with what, when, where, how, and how often are likely to provide specific, useful information. Questions that begin with why can be conversation stoppers, leading to peripheral topics and convoluted responses. For that reason, they are not recommended.
Remember that objectives for change must be SMART, that is, specific, measurable, attainable, realistic, and tangible. They need to "fit" patients and their situations, including their readiness, environment, resources, conviction, and confidence.
Such a realistic point of view supports change. For example, in the past Kathy had made several efforts to stop smoking, without success. This time she prepared by attending classes at the local hospital, identified times when she usually smoked, planned other activities at those times, and arranged with friends for support when she needed it. As a result, she now has a specific, measurable, attainable, realistic, and tangible objective to "become a nonsmoker on September 1."
Clinicians who see themselves as change agents assess patients in a different way than caregivers who do not. Change-agent clinicians are action-oriented, ready to identify specific measurable objectives for change that will help patients reorder their lives. These caregivers ask themselves four essential questions:
The answers to these questions guide clinicians as they plan interventions to help patients move toward their objectives. If patients are in the very first stage of change, the caregiver focuses on measures that will move them to the second stage of change, the contemplation or "mull it over" stage when people intend to change in the next 6 months (Tilton, 2006). If patients lack conviction or confidence, the caregiver works with them to increase their motivation. If barriers are preventing change, the caregiver works with patients to overcome those blocks and achieve their objectives.
The two essential elements in the process of change are conviction that an outcome is important and confidence that it can be achieved. When there is strong conviction and confidence, the person is motivated to act. One way to assess just how motivated a person might be is to ask the following questions:
Conviction and confidence interact to determine a person's commitment to change. For example, at the moment you may have high conviction that change is important but low confidence that you can become an effective change agent.
Ideally, everyone would have high conviction of the importance of a specific, measurable, attainable, realistic, and tangible objective for change and high confidence that they can achieve their objective. When such ideals are not present, some interventions to enhance conviction and confidence include the following:
Earlier, we mentioned that change does not proceed in a straight line, without variation, toward an identified outcome. Often, the path and the pace of change are uneven. One of the reasons for this inconsistency is that people are ambivalent. On the one hand, they want to achieve a new behavior, but on the other hand the process takes energy and effort. Besides, the old behavior was familiar and comfortable. As a result, conviction and confidence weaken.
Clinicians can help people overcome ambivalence in several ways. They can show sincere empathy by admitting that change is difficult and takes courage, reflecting back the very same words patients have just said. For example, the caregiver may say, "When you are tired or upset, you 'miss sitting down and having a cigarette.'" By reflecting back, patients hear what they expressed and are able to acknowledge their feelings. They can then renew their commitment to change.
Another useful technique to help people deal with ambivalence is summarizing what a patient has accomplished. For instance, "You have been a nonsmoker for 35 days. By now the oxygen levels in your blood have returned to normal, your clothing no longer smells of tobacco, and you have saved a whole lot of money."
Another technique is to acknowledge progress and respond to the positive change statements of an individual: "I thought I would gain weight when I stopped smoking, but so far, I haven't." The caregiver might respond, "Good for you! You must be eating healthy foods and staying active."
Finally, the clinician can explore ambivalence by asking the following questions:
As change agents, healthcare professionals realize that even when their patients are well along on the path toward their objective, they must work to prevent relapse. Though patients are more confident that they can continue their identified change, they are still vulnerable. For this reason, caregivers need to arrange and encourage follow-up measures such as ongoing visits, membership in support groups, participation in managed care, and mentoring to help people maintain the changes they have worked so hard to achieve.
When patients do "crash," regressing to an earlier stage of change, their self-confidence briefly vanishes and they feel as if they have failed. Happily, there is good news. Research indicates that only 15% of smokers regress all the way back to the precontemplation stage of change. Most people who crash go back only one or two stages and then are able to move forward again (Tilton, 2007). Their conviction that their objective is important is still intact and though their confidence is weakened it persists. It is at these times that healthcare providers need to build up individuals and give them support and encouragement until they once again are achieving their goal.
Austin MM. (2006). Yes, You Can! Helping Patients Change Behavior. AODA Conference, Dublin, IR. Retrieved March 2006 from MAustinRD@aol.com.
Bennis WG, Benne KD, Chin R, Corey KE. (1976). The Planning of Change, 3rd ed. New York: Holt, Rinehart, & Winston.
Duncan WJ. (1978). Essentials of Management, 2nd ed. New York: Dryden.
Prochaska J, et al. (1994). Changing for Good. New York: Morrow.
Rogers C. (1961) On Becoming a Person. New York: Norton.
Sampson E. (1979). Social Psychology and Contemporary Society, 2nd ed. New York: Wiley.
Tilton D. (2007), Motivating Adherence to Plans of Care. Retrieved April 2006 from http://www.nursingceu.com/courses/73/index_nceu.html.
GET THE WILD IRIS NEWSLETTER!
TherapyCEU.com is a division of Wild Iris Medical Education
Copyright © 1999-2010 Wild Iris Medical Education, Inc.
Photograph © 2008 Jon Klein
Get discounts, special offers, and information.
We do not sell, rent, or share our mailing list.
