Wild Iris Medical Education
COURSE PRICE: $10.00
CONTACT HOURS: 1
This course will expire or be updated on or before November 3, 2013.
ABOUT THIS COURSE
You must score 70% or better on the test and complete the course evaluation to earn a certificate of completion for this CE activity.
ACCREDITATION / APPROVAL
Wild Iris Medical Education, Inc. is a Continuing Competency Approval Agency recognized by the Physical Therapy Board of California.
Approval of physical therapy continuing education credit varies by state. Confirm approval with your state's licensing agency before you take the course for CE credit. See Physical Therapy CE Approval for more information.
Wild Iris Medical Education, Inc. provides educational activities that are free from bias. The information provided in this course is to be used for educational purposes only. It is not intended as a substitute for professional health care. See our disclosures for more information.
Copyright © 2011 Wild Iris Medical Education, Inc. All Rights Reserved.
COURSE OBJECTIVE: The purpose of this course is to describe the nature of change, explain how conviction and confidence interact to motivate change, and identify actions that facilitate change.
Upon completion of this course, you will be able to:
Healthcare providers are in the business of helping people solve problems—problems they cannot solve themselves or conditions they may not know they have. As healthcare providers, we listen, ask questions, examine, conduct tests, and consult with others. By so doing, we diagnose problems and develop plans of care to resolve them. To effect change, however, individuals with problems must take some action themselves.
Often the action is quick and easy, as when a caregiver says, “Take this prescribed medication once a day for five days,” “Wear this splint for three weeks,” or “Apply this ointment twice a day for ten days.” At other times, the action is long and difficult, as when a caregiver says: “Stop smoking,” “Learn to live with diabetes,” or “Move to an assisted-living facility.”
Even when a change in behavior is relatively simple, like taking a pill, people are remarkably resistant to change. Research tells us that 20% of patients fail to fill new prescriptions and about 50% of people with chronic health conditions discontinue taking medications within 6 months of the time they are prescribed (NIH, 2010).
Knowing this, healthcare providers who really want to help people must do more than hand folks a prescription and tell them to return at some future time “to see how you’re doing.” Caregivers must become change agents. Change agents motivate, educate, and support individuals throughout the process of change, even though it may be difficult and frustrating. To do this healthcare providers need to:
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. Often, change occurs haphazardly. Even when it is planned and specific outcomes are identified, change seldom proceeds in a straight line or at a steady pace because it is affected 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 (1976) identified eight types of change:
Sampson (1979) suggested three kinds of change:
Duncan (1978) argued for only two types of change:
Notice that every one 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 about a goal. 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 health. His physician recognizes the need for Jim to learn about his disease. Using a content-driven approach to patient education, the doctor gives Jim several pamphlets about diabetes, refers him to a diabetes website, and suggests Jim might be interested in attending classes offered by the local hospital. Though Jim reads the brochures and information he finds on the website, he does not understand how to apply it to his condition, nor does he grasp the seriousness of the red, swollen area on his foot that never seems to heal.
A more effective method of bringing about planned change in clients like Jim is to use an outcome-driven approach. This approach focuses on specific, measurable objectives. Information is personalized and related to specific goals.
When Jim attended the class at the hospital, he realized he needed much more information as it applied to his situation. He asked the patient educator for help. The educator consulted with Jim’s physician and identified 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. She encouraged him to talk about his fear of blood and pain. Then, she demonstrated the procedure and discussed problems that might arise in performing the test. Jim mirrored her demonstration until he could do it accurately, every 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. Studies indicate that motivation to change requires both conviction and confidence:
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 conviction and confidence, 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 steps or states. 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) precontemplation, (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. They become aware of or sensitive to a situation or condition in their life that is not beneficial to them. For example, Kathy has smoked cigarettes for more than 25 years. She feels angry every time she buys cigarettes because of their high price and says she knows smoking is not healthy. Kathy thinks about quitting, but she views the task as very difficult and beyond her ability to accomplish.
Contemplation is the stage when an individual intends to change some behavior relatively soon, say in the next 6 months. For example, Kathy understands the benefits of not smoking. She says she really wants to quit and starts talking to her friends about the process. But she keeps putting it off, stuck in procrastination due to her doubts about her ability to quit. Often, people in the contemplation stage are not yet truly ready to change.
Preparation is the stage in which an individual decides to take action to change. Often something happens to motivate the person to take action, such as an emotion-laden crisis, recent illness, or plea from an important person in their life. In Kathy’s case, repair of her umbilical hernia became more urgent. The surgeon suggested she stop smoking in preparation for the general anesthesia the surgery would require. He assured her she could stop, even after 25 years of smoking. Thus, Kathy’s conviction of her need to stop smoking increased and her confidence in the ability to succeed grew as a result of the encouragement of her caregiver.
Action is the stage in which people actually modify their behavior. They develop new habits and work toward what some have called “SMART objectives.” These objectives are specific, measurable, attainable, realistic, and time-bound. During the action stage, people need to remain convinced and confident they can and will change their behavior.
SMART OBJECTIVES
Many people are likely to relapse into old behaviors. Maintenance is the stage in which people work to prevent such relapse. They are tempted to go back to their old behaviors and need ongoing support to develop new patterns of living. Such support is enhanced by encouragement from primary care providers, colleagues, friends, and members of self-help groups. In our example, Kathy joined a Stop-Smoking support group where members gave her tips they used to prevent relapse. Also, they gave her encouragement to continue her quest to become a nonsmoker.
To bring about behavioral change, healthcare providers use a variety of techniques to support clients in making significant, health-producing changes in their lives. Caregivers show nonjudgmental empathy, listen attentively and reflectively to patients, use both verbal and nonverbal messages, support measurable objectives, take into account their stage of change, assess their level of conviction and degree of confidence toward change, and arrange a variety of follow-up measures to encourage patients to maintain the changes they have made.
When a patient comes to a healthcare professional with a problem, the first challenge is to establish a relationship of trust with that individual. Caregivers do this by giving the person their undivided attention, focusing on that person alone. They seek to gather not only objective facts, but also to understand the emotional, subjective components of the problem and its meaning to the patient.
By so doing, healthcare providers demonstrate genuineness, accurate empathy, and unconditional positive regard (Carkhuff, 1977). As a result, patients feel understood and truly heard. For example, the caregiver might say, “I think I understand how you feel… . Please tell me more.”
Another useful technique for building rapport is called reflective listening. The goal of such listening is to express interest and to understand what the speaker is saying. For example, the clinician asks, “How are you doing today?” When the patient replies, “Oh, I guess I’m all right,” the clinician notices the glum tone of 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 a person’s welfare. This behavior encourages trust. As a result, the patient is more likely to express genuine 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 an individual, nodding, listening intently, and making eye contact—indicate sincerity and build rapport. Another useful technique is the judicious use of silence. Such behavior demonstrates respect and 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 usually provide more specific and useful information than why. Questions that begin with why encourage convoluted responses and lead to peripheral topics. For this reason, they are not recommended.
Remember, objectives that lead to change should be SMART—specific, measurable, attainable, realistic, and time-bound. Objectives need to “fit” individuals 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 unsuccessful efforts to stop smoking. This time her doctor suggested she attend classes at the local hospital. The educator helped her identify times when she usually smoked, plan other activities at those times, and arrange with friends for support when she needed it. As a result, she now has a specific, measurable, attainable, realistic, and time-bound objective to “become a nonsmoker beginning January 1.”
Healthcare providers who see themselves as change agents assess patients in a different way than caregivers who do not. Change-agent clinicians are action-oriented and 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 (precontemplation), the caregiver focuses on measures that will move them to the second stage of change (contemplation), the “mull it over” stage when people intend to change in the next 6 months.
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. 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.
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 someone may have high conviction that change is important but low confidence that they can become an effective change agent.
Ideally, everyone would have high conviction in the importance of a specific, measurable, attainable, realistic, and time-bound 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:
Another technique is to acknowledge progress and respond to the positive change statements of an individual. For instance, to the statement “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 lack of confidence 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. 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.
Thus far, we have discussed how healthcare providers can help people change, proceeding from the assumption that people want to change their behavior and just need help to do so. But some people who have problems do not want to change. These people may be:
Caregivers cannot force adults to seek help to change, however in our contacts with them, we can encourage them and assure them that we are there to help them change.
Bennis WG, Benne KD, Chin R, Corey KE. (1976). The Planning of Change (3rd ed.). New York: Holt, Rinehart, & Winston.
Carkhuff RR. (1977). The Art of Helping (2nd ed.). Amherst, MA: Human Resource Development Press, Inc.
Duncan WJ. (1978). Essentials of Management (2nd ed.). New York: Dryden.
NIH Office of Behavior and Social Sciences Research. (2010). “Request for Information: Priorities for the NIH Adherence Research Network.” Retrieved July 6, 2010 from http://grants.nih.gov/grants/notice-files/NOT-OD-10078.html.
Prochaska J, et al. (1994). Changing for Good. New York: Morrow.
Sampson E. (1979). Social Psychology and Contemporary Society (2nd ed.). New York: Wiley.
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