Dr Nicola J Davies
Health Psychology Consultancy, 12 Hitchin Lane, Clifton, Shefford, Bedfordshire, SG17 5RS
Keywords: Health; Lifestyle; Behaviour Change
Lifestyle-related Health Behaviour Change
The Nurses Role
Despite being preventable, lifestyle-related illness is of huge personal and economic burden. Lifestyle is notoriously difficult to change for a number of psychological, biological, and environmental reasons.
Current policy guidance identifies a key role for nurses in helping people to adopt and sustain healthier lifestyle-related behaviours.
Nurses’ efforts to promote healthy lifestyles can be facilitated by the adoption of evidence-based techniques gained from health behaviour change theories.
Motivational interviewing skills can 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 develop patient confidence 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 methods of approaching behaviour change in clinical practice.
In an independent report offering recommendations on enabling effective delivery of health and well-being in England, Bernstein, Cosford, and Williams (2010) advise that setting clear priorities for health and well-being should start with behavioural risk factors. Namely, they recommend tackling the biggest lifestyle influences on population health: tobacco, alcohol, physical inactivity and poor diet. These four lifestyle factors are among the biggest contributors to most preventable diseases, across all social groups and in all areas of England. They are responsible for 42% of deaths from leading causes and together they account for at least ?9.4 billion in annual direct costs to the NHS (DH, 2009). Low physical activity is the most prevalent chronic disease risk factor, with 95% of the adult population not meeting the physical activity guidelines of at least 30-minutes a day of moderate intensity physical activity five or more days of the week (Troiano et al., 2008). Encouraging healthy behaviours in relation to diet, physical activity, smoking, and alcohol consumption, is likely to improve individual health and quality of life by reducing the incidence of lifestyle-related illness. Current policy guidance identifies a key role for nurses and other frontline staff in helping people to adopt and sustain a healthier lifestyle (RCN, 2007). Furthermore, evidence suggests that patients would prefer lifestyle interventions to be delivered by nurses as opposed to doctors (Locke, 2004). This article describes some of the most effective, evidence-based behaviour change techniques that nurses can utilise in practice. First, the influences of health behaviour will be outlined, followed by a description of some of the key theories within the field of health-related behaviour change.
THEORIES OF HEALTH-RELATED BEHAVIOUR CHANGE
There is accumulating evidence regarding the cognitive, emotional and environmental factors that influence health-related behaviour (Table 1). As a result, health professionals are being encouraged to target patients’ attitudes and beliefs in their efforts to improve health-related behaviour.
TABLE 1. FACTORS INFLUENCING LIFESTYLE-RELATED HEALTH BEAHVIOURS
Social and material environment
People’s views or judgements in relation to their health.
People’s opinions or convictions in relation to their health.
The process that drives health behaviours.
A plan of action intended to affect one’s health.
The act of making a conscious choice in relation to health.
To form specific aims and objectives in relation to health.
The psychical and emotional assistance of important people.
The ability to measure and assess one’s health.
The modification of factors and influences in the environment that will bring about a health benefit.
The factors influencing health behaviours are best illustrated within the five theoretical models represented in projects funded by the National Institute of Health (NIH): Social Cognitive Theory, Transtheoretical Model, Motivational Interviewing, Self-Determination Theory, and Social Ecological Theory (Table 2).
TABLE 2. BEHAVIOUR CHANGE THEORIES AND MODELS
Transtheoretical Model (Stages of Change) (Prochaska, DiClemente, and Norcross, 1992)
Behaviour change is determined by readiness to change, which comprises five distinct stages:
Pre-contemplation: not yet acknowledging an unhealthy behaviour.
Contemplation: acknowledging the unhealthy behaviour, but not yet ready to change.
Preparation: getting ready to change.
Action: changing the unhealthy behaviour.
Maintenance: remaining abstinent.
Social Cognitive Theory (Bandura et al., 1989)
Behaviour change is determined by a combination of personal and environmental influences, including observational learning, capacity, outcome expectancy (a belief that behaviour change will be successful), self-efficacy (a belief that one is capable of behaviour change), and positive reinforcement for attempts to change.
Self-Determination Theory (Deci and Ryan, 1985)
The patient’s experiences of autonomy, competence, and relatedness (the effort made to relate to others and be concerned for them; feeling accepted by others and experiencing satisfaction with the social world) are affected by autonomy-supportive health care environments, individual differences in personality, and the intrinsic and extrinsic nature of the patient’s goals and aspirations. When humans feel their psychological needs are being supported, they tend to have better mental health, greater quality of life, and better health-related outcomes, such as greater intake of fruits and vegetables, reductions in smoking, increases in physical activity, and improved adherence to healthcare advice.
Social Ecological Theory (Bronfenbrenner, 1994)
The concept of a health-promoting environment whereby behaviour is described as a series of layers, where each layer has a resulting impact on the next level. The inner level represents the individual, which is then surrounded by differing levels of environmental influences. For example, the social environment of family, friends and workplace are embedded within the physical environment of community facilities, which is in turn embedded within the policy environment of different levels of governing bodies. All levels of the social-ecological model impact on the behaviour of the individual.
Motivational Interviewing (Miller and Rollnick, 2002)
Motivational interviewing is a person-centred, directive method for enhancing intrinsic motivation to change by exploring and resolving any behaviour change ambivalence. The technique is underpinned by a belief that the patient is the expert in their own lives and that people are generally better persuaded by their own reasons for behaviour change than by the reasons of others.
There is accumulating evidence that behaviour change interventions based on these five theories can be effective in changing health-related behaviour. It has also been shown that acquisition of a theoretical understanding of behaviour change techniques can improve the likelihood of health professionals being successful in behaviour change 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 lifestyles. This evidence has been utilised in the National Centre for Smoking Cessation and Training programme (NCSCT, 2010), which was designed to provide evidence-based competencies most likely to deliver effective outcomes for smoking cessation. With lifestyle remaining a key priority within the government’s agenda, there is a need to ensure that healthcare providers, including nurses, have the competencies required to deliver brief behaviour change interventions.
COMMUNICATING PATIENT-CENTRED CARE
Good verbal and behavioural communication between patient and health professional is fundamental to behaviour change attempts and patient outcomes. Indeed, studies have shown that patient-centred care is associated with better adherence to behaviour change (Robinson et al., 2008). Key communication skills in patient-centred care include ascertaining reasons for accessing healthcare service, finding common ground, providing information, and sharing decisions. Furthermore, researchers have identified a list of verbal and non-verbal behaviours that are associated with favourable patient outcomes in terms of behaviour change (Figure 1).
FIGURE 1. PATIENT-CENTRED COMMUNICATION SKILLS FOR BEHAVIOUR CHANGE (Beck, Daughtridge, and Sloane, 2002).
Reassurance and support
Addressing the feelings and emotions of patients
Increased time on health education
Receptivity to patient questions and statements
Allowing the patients point of view to guide the conversation in the concluding part of the consultation
In comparison, passive acceptance, formal behaviour, antagonism and passive rejection, high rates of biomedical questioning, interruptions, irritation, dominance, and a one-way flow of information from patient (i.e. information collection without feedback) have all been associated with negative patient outcomes.
Healthcare professionals have been found to be poor at micro-skills, such as asking open directive questions like “How do you feel aboutaˆ¦..?” (Parle, 1997). In general, health professionals fear that asking open questions in order to promote behaviour change will ‘open a can of worms’ and result in emotional reactions that they are unable to deal with, such as depression, fear, or hostility. Health professionals have also been found to find it difficult to communicate in challenging situations, like when a patient is in denial.
Other reason that nurses and other health professionals might avoid engagement in behaviour change techniques is a shortage of time. This problem is likely to become even more prominent due to an increase in healthcare utilisation during financially difficult times. Notably, nurses are more likely to implement behaviour change techniques, such as asking patients about their diet, compared to allied health professionals (Laws et al., 2008). However, when barriers are present, knowledge of theory and evidence-based guidance can be used to facilitate communication and provide nurses with a realistic benchmark to measure the effectiveness of their communication skills in promoting behaviour change.
OPERATIONALISING THEORY INTO PRACTICE
Motivational interviewing provides a non-confrontational way of raising the topic of lifestyle with patients, thus overcoming at least one of the barriers to such interactions. Motivational interviewing is a rapidly utilised approach that improves the quality of the nurse-patient interaction. In motivational interviewing, emphasis is placed on two key aspects of patients’ speech, which can be used to guide efforts to help the patient; these are ‘Change Talk’ and ‘Resistance.’ Change talk can be detected via verbal signals indicative of a desire and commitment to change. Most resistance talk, on the other hand, is an oppositional reaction to behaviour change discussions.
Health baseline comparisons (HBCs), which have been theorised as influencing health-related behaviours, offer a valuable starting point for exploring people’s lifestyle-related attitudes and beliefs (Davies et al., 2008). HBCs are the reference point adopted by people when they are evaluating their health status and thus determining whether any changes need to be made. These are not always productive of healthy lifestyle choices such as when, for example, a person who smokes evaluates their health as good because they eat five pieces of fruit a day. In such an encounter, nurses can use motivational interviewing techniques to guide patients towards a more realistic evaluation of their health status.
Motivational interviewing is a technique that requires consistency in several core communication skills and is frequently delivered with the aid of several tools and strategies (Table 3). It is collaborative in that the health professional works with and alongside the patient, addressing their concerns and helping them make progress towards their goals. It also increases patient autonomy with the health professional remaining mindful that the patient is the active decision maker. The technique is underpinned by a belief that the patient is the expert in their own lives and that people are generally better persuaded by their own reasons than that of others.
TABLE 3. MOTIVATIONAL INTERVIEWING SKILLS AND STRATEGIES
Key Communication Skills
Tools and Strategies
Role with resistance
Resist the righting reflex
Understand the patient’s dilemma
Listen to the patient
Empower the patient
Reflective listening statements
Summaries to communicate understanding
Setting the scene
Agreeing on the agenda
Exploring a typical day
Exploring two possible futures
Looking back and looking forward
Agreeing to a plan
Autonomy in decision-making is crucial for the maintenance of new, healthier behaviours. Many health behaviour change interventions fail because they immediately target behaviour rather than the underlying attitudes that drive behaviour. However, by assessing motivation to change and establishing those whose attitude is conductive of change, nurses can allocate their time and resources wisely. If a patient is motivated to change, then they may merely require information and a support system. If they are not motivated to change, the use of motivational interviewing might either instantly change their attitude or give them 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 attempt. By establishing their readiness to change and their motivation to change, the nurse, by adopting a motivational interviewing approach has identified the most efficacious course of action. Sometimes the best course of action is to accept the patients resolve to continue with unhealthy lifestyle choices, in the knowledge that you have at the very least increased their health literacy so that they can make informed lifestyle decisions.
The utility of this approach is supported further within the Transtheoretical Model of behaviour change, which is described next.
Readiness to Change
The Transtheoretical model, perhaps better known as the ‘stages of change’ model, purports that individuals modify their behaviour through a series of five distinct stages (Prochaska, DiClemente, and Norcross 1992):
Stage 1: Pre-contemplation
Not yet acknowledging an unhealthy behaviour that needs to be changed.
Stage 2: Contemplation
Acknowledging the unhealthy behaviour, but not yet sure whether one is ready or wants to change.
Stage 3: Preparation
Getting ready to change, perhaps setting a quit date.
Stage 4: Action
Changing the unhealthy behaviour.
Stage 5: Maintenance
Some people move through the stages of change, but most individuals will relapse and return to earlier stages. This pattern 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 behaviour change interventions are shown in Table 4. Helping relationships, consciousness raising, and self-liberation have been found to consistently be the top three ranked processes regardless of targeted health behaviour (e.g. diet, smoking). Helping relationships and consciousness raising are implicit in the nurse-patient dynamic, and self-liberation is something which nurses can help patients with through education and support.
TABLE 4. TEN PROCESSES OF CHANGE
Increasing information about unhealthy behaviour.
Assessing personal feelings about an unhealthy behaviour.
Choosing and committing to change.
Replacing unhealthy behaviours with substitutes.
Avoiding stimuli that prompt unhealthy behaviours.
Self-rewards or rewards from others for making changes.
Being open and trusting with someone who cares.
Finding solutions to behaviour change barriers.
Assessing how barriers affect physical environment.
Increasing opportunity for healthier behaviours.
Based on the Transtheoretical Model, in order to be effective behaviour change interventions need to be designed and tailored according to the stage of the individual. For example, action-oriented interventions are unlikely to produce successful outcomes in people who are in the pre-contemplation stage and have not yet acknowledged the need to change.
This model illustrates that if a patient leaves the consultation having moved from pre-contemplation (i.e. does not recognise a need to change an unhealthy behaviour) to contemplation (i.e. is considering the need to change an unhealthy behaviour), they are one stage closer to initiating a behavioural change likely to improve their health and quality of life. Thus, the goal for nurses is to provide patients with the information and support needed to facilitate informed decision-making around health-related behaviours. Indeed, helping the patient to recognise for themselves the need to change will ultimately increase self-motivation and the likelihood of sustained long-term change.
On establishing that a patient is motivated and ready to change an unhealthy behaviour, evidence-based techniques can be operationalised to assist them achieve their desired outcome, whether this be to stop smoking or to do more exercise. Of primary concern should be the patients’ level of self-efficacy (Bandura et al., 1989) as this can influence both the initiation and maintenance of behaviour change. Self-efficacy refers to confidence in one’s ability to achieve the desired behaviour change. Evidence suggests that individuals high in self-efficacy are more resilient when confronted by barriers or relapse. Someone with low self-efficacy, on the other hand, is more likely to give up after 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 systematic review of physical activity interventions to improve daily walking activity in cancer survivors (Knols et al., 2010), a distinct difference was found between those interventions that produced significant behaviour change and those that did not – goal-setting was present in the former. Importantly, these goals need to be realistic and obtainable, as well as set by the patient, 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 three times throughout the day when 20-minutes in one go might seem too much. Realistic goal-setting is particularly important at the beginning of attempts to change behaviour when failure is more likely to reduce motivation.
According to Bandura et al. (1989), self-efficacy can be enhanced in four ways:
Mastery: success raises self-efficacy, failure lowers it.
Vicarious experience: when people see someone succeeding at something, their self-efficacy will increase, but when they see people failing, their self-efficacy will decrease.
Verbal persuasion: positive feedback increases self-efficacy and negative feedback decreases it.
Physiological feedback: subjective perceptions of physiological responses can alter self-efficacy (e.g. breathlessness after exercise can be interpreted as a sign of a good workout or a sign of being unhealthy).
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 commit to a date when they will initiate behaviour change; helping them preparing in advance for potential barriers to change, etc.)
Reinforcing effort or progress towards behaviour (i.e. praising or encouraging behaviour change efforts)
Instruction (i.e. demonstrating how a piece of exercise equipment is used, and providing guidance on how to cook more healthily, etc.).
These strategies can be combined so that a patient is helped to set a realistic goal that can be achieved via a written action plan that comprises a time limit, instruction, and the inclusion of a reward system. It is 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-days per week. Efforts to achieve this goal could be rewarded with words of encouragement, whilst actually achieving the goal could be self-rewarded with, for example, a new dress or a meal out with friends.
THE 5 A’S FRAMEWORK
A useful way of remembering the order in which to apply behaviour change strategies is to adopt the 5 A’s approach (Elford, 2000). The 5 A’s – Asses; Advise; Agree; Assist; Arrange – have been recommended by the Canadian task force on preventative healthcare as being the gold standard model for behavioural counselling. It is believed that clinical interventions targeting any lifestyle-related behaviour can be described with reference to these five components.
The first stage is to assess the patients’ awareness of any unhealthy behaviours, as well as their motivation and readiness to change. Advice and information can then be provided on the specific risks and benefits associated with a particular health behaviour as well as any support services available to help the patient. Once the patient has been fully informed, nurses can work collaboratively with them to agree a set of achievable, measurable goals. Assistance can be provided in terms of skills development, barrier identification, problem-solving, and social support, all of which will facilitate the achievement of goals. Arranging follow-up with the patient provides the opportunity to conduct a re-assessment as well as to monitor progress and adjust any action plans accordingly. This might be through face-to-face visits, telephone calls or other forms of contact. Systematic, routine assessment also allows interventions to be adapted as the individual changes and presents with differing needs. Throughout all stages, motivational interviewing skills can be applied as a method of engaging the patient with open-ended questions productive of enhancing patient autonomy whilst also increasing motivation.
Research suggests that long-term behaviour change is unlikely to be sustained without the active engagement of health professionals. By taking an interest in a patient’s lifestyle and engaging them in behaviour change communication, nurses are endorsing a healthy lifestyle, enhancing patient health and well-being, and taking primary and secondary preventative measures. This supports the Chronic Care Model (Wagner, 1998), which has been extensively used in the redesign of primary care systems. According to this model, the essential element of good care for people with chronic conditions is a productive interaction between health professional and patient. To deliver quality outcomes, for patients and healthcare services, frontline staff need to work towards creating informed activated patients who have goals and a plan to improve their health. Nurses are well placed to deliver this vision through information provision, support, and a wealth of evidence-based health-related behaviour change techniques (Table 5).
TABLE 5. BEHAVIOUR CHANGE TECHNIQUES
Providing general information about risks associated with particular health choices, as well as about the benefits and costs of action or inaction in terms of changing behaviour.
Prompt intention formation
Encouraging an individual to decide to act or to set a goal.
Identifying barriers to change and planning ways to overcome these barriers.
Providing praise and positive feedback on behaviour change efforts and successes.
Setting easy tasks, and increasing task difficulty until behaviour change has been achieved.
Showing an individual how to correctly perform a particular behaviour.
Involving the detailed planning of what the person will do, including specific details on frequency, intensity, location, duration, etc. Reviewing goals and modifying goals.
Asking the individual to keep a diary or record of specified behaviours.
Prompts and cues
Teaching an individual to use prompts or cues that can remind them to perform the behaviour.
Agreement of a contract specifying the behaviour to performed (e.g. a written record of a resolution to behaviour change).
Prompting repetition of desired behaviours.
Providing opportunities for individuals to compare themselves with peers who have successfully mastered a specific behaviour.
Prompting consideration of how others could change their behaviour to offer the person help, including ‘buddy’ systems.
Prompting the individual to provide self-motivating statements and evaluations of their own behaviour to minimise resistance to change.
Helping the individual make time for the behaviour