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COURSE OBJECTIVE: The purpose of this course is to give a better understanding of the concept of change and offer healthcare professionals practical strategies for helping people change their health-related behaviors.
Upon completion of this course, you will be able to:
An essential role of healthcare professionals is helping people solve problems—problems they cannot solve themselves or conditions they may not know they have. As healthcare professionals, we listen, ask questions, examine, conduct tests, and consult with others. By so doing, we help diagnose problems and then develop plans of care to resolve them. However, to effect real change, individuals with problems must “own” and adhere to the plan and take action to implement it.
Often the action is quick and easy, as when a patient follows the directions of a caregiver, such as, “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.”
Recognizing the resistance to change, healthcare professionals who really want to help people change must do more than simply hand out a prescription and tell someone to return at some future time “to see how you’re doing.” That caregivers must become change-agents, as described in Miller & Rollnick (2002), has itself stood the test of time. Change agents motivate, educate, and support individuals throughout the process of change, even though it may be difficult and frustrating. To accomplish this, healthcare professionals must:
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 several decades. The table below indicates the types of change identified in early research on the topic.
|Bennis et al. (1976)||Duncan (1978)||Sampson (1979)|
All of these pioneer 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 professionals differ regarding the most effective way to bring about such an end. 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.
A more effective method of bringing about planned change in clients is to use an outcome-driven approach. This approach focuses on specific, measurable objectives. Information is personalized and related to specific goals.
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 he attend 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.
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.
A 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 seek help must be motivated to do something. Studies indicate that motivation to change requires both conviction and confidence.
Without both of these 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 (Rollnick et al., 2007).
Three factors interact to influence change—the clinician, the environment, and the patient:
In the face of today’s increasing shift toward team-based care and the consequent reduction in ongoing relationships between patient and physician, new models of interactive behavior change are being investigated. For instance, a recent study found that health behavior change was possible by connecting patients with mobile technology, incentives, and remote, nonphysician coaches to improve their diet and physical activity levels (Spring et al., 2012). The coaches helped participants set daily goals, and the participants used handheld digital devices to record and regulate their targeted behaviors. The devices displayed goal “thermometers” as a source of feedback and also provided information on the impact of a food or activity choice.
Change occurs in a series of steps or stages. These stages are especially noticeable if the change represents a significant alteration in lifestyle. One model, the Transtheoretical Model of Behavior Change, is applied to a variety of behaviors, populations, and settings, both in research and clinical work (Prochaska, 1994; UMBC, 2013). This model identifies five sequential stages that people experience as they change from old behaviors to new ones: 1) precontemplation, 2) contemplation, 3) preparation, 4) action, and 5) maintenance.
Precontemplation begins when individuals consciously recognize the need to change a behavior but do not know how to do it. They become aware of or sensitive to a situation or condition in their life that is not beneficial.
Contemplation is the stage when individuals intend to change some behavior relatively soon, say in the next 6 months. Often, people in the contemplation stage are not yet truly ready to change. They may procrastinate or doubt their ability to change.
Preparation is the stage in which individuals decide to take action to change. Often something happens to motivate a person to take action, such as an emotion-laden crisis, recent illness, or plea from an important person in their life. Encouragement from a caregiver can help a patient decide to act.
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.
|Specific||“I will no longer smoke cigarettes or any other substance.”|
|Measurable||“I will keep not one cigarette, even an ‘emergency smoke,’ in my environment.”|
|Attainable||“I have overcome other cravings. Other folks have stopped smoking, and I can too.”|
|Realistic||“Smoking is not necessary for survival, and in fact, it may kill me.”|
|Time-bound||“I will stop smoking on January 1, the beginning of a new year.”|
Many people 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.
Kathy has smoked cigarettes for more than 25 years. She feels angry every time she buys cigarettes because of their high price, and she knows smoking is not healthy. She says she really wants to quit, but she’s tried and failed in the past and doesn’t think she can do it. She starts talking to her friends about trying again to quit, but she keeps putting it off, stuck in procrastination due to her doubts about her ability to do it.
As the need for surgery to repair her umbilical hernia becomes urgent, Kathy’s surgeon suggests she stop smoking in preparation for the general anesthesia the surgery will require. He assures her she can quit. As a result, Kathy’s conviction increases in the need to stop smoking and her confidence grows in her ability to succeed.
Kathy is ready to quit. First she attends smoking cessation classes offered by the local hospital. The educator helps her identify times when she usually smokes, plan other activities at those times, and arrange with friends for support when she needs it. Kathy learns of the “SMART” objectives and sets January 1 as her date to quit.
Once the new year rolls around, Kathy realizes she’ll need help, so she joins a community support group of other long-time smokers, all of whom are determined to stop smoking. Over the weeks, the other members encourage Kathy and give her tips to prevent relapse.
Kathy is in the precontemplative stage of change when she considers the detrimental aspects of smoking, its expense, and damage to her health. She moves into the contemplative stage when she begins thinking about quitting and struggles with her doubts about being able to do so. With the encouragement of her surgeon, Kathy enters the preparation stage. The action stage begins when Kathy attends the smoking cessation class and sets a date for quitting. Her ongoing participation in the community support group represents the maintenance stage.
To bring about behavioral change, healthcare professionals use a variety of techniques to support clients make significant, health-promoting changes in their lives. They:
When used by a therapist, these techniques are included in what has been called motivational interviewing (Miller & Rollnick, 2002).
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 professionals 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 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.
Healthcare professionals 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. Some interventions to enhance conviction and confidence include:
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 confident they can continue their identified change, they are still vulnerable. For this reason, caregivers need to arrange and encourage follow-up measures to help people maintain the changes they have worked so hard to achieve, such as ongoing visits, membership in support groups, participation in managed care, and mentoring.
When patients do “crash” and regress to an earlier stage of change, their self-confidence may vanish and they may feel they have failed. Happily, research indicates that in the case of smokers, only 15% regress all the way back to the precontemplation stage of change. Most of those who crash go back only one or two stages and then move forward again. Although their confidence is weakened, it persists, as does the conviction that the objective is important. It is during these times that encouragement by healthcare professionals helps people achieve their goal.
Thus far, we have discussed how healthcare professionals can help people change their behavior, assuming that they want to change and only need the encouragement of a professional. However, some people with 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 flourish.
Although the focus of this course has been to give healthcare professionals useful information about change and strategies to help clients change their health-related behaviors, the same principles and techniques can be used to effect change in other circumstances of life. They can be applied to the personal lives of healthcare professionals, the organizations in which they work, and the communities where they live.
NOTE: Complete URLs for references retrieved from online sources are provided in the PDF of this course (view/download PDF from the menu at the top of this page).
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.
Miller WR & Rollnick S. (2002). Preparing people to change. New York: Guilford Press.
NIH, Office of Behavior and Social Sciences Research. (2010). Request for information: priorities for the NIH adherence research network. Retrieved from http://grants.nih.gov
Prochaska J, et al. (1994). Changing for good. New York: Morrow.
Rollnick S, Miller WR, & Butler CC. (2007). Motivational interviewing in health care: helping patients change behavior. New York: Guilford Press.
Sampson E. (1979). Social psychology and contemporary society (2nd ed.). New York: Wiley.
Spring B, Schneider K, McFadden G, Vaughn, J, Kozak AT, Smith M, Moller AC, Epstein LH, et al. (2012). Multiple behavior changes in diet and activity: a randomized controlled trial using mobile technology. Arch Intern Med, 172(10), 789–96.
University of Maryland, Baltimore County (UMBC), Habits Lab. (2013). Transtheoretical model of behavioral change. Retrieved from http://www.umbc.edu