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Lifestyle change
Many long-term conditions can be prevented by simple lifestyle changes. Nurses can
Healthier lifestyles:
draw on a number of theories to help them support patients to change behaviour
behaviour change
This article... for Smoking Cessation and Training pro-
gramme (2010), which provides evidence-
Effective techniques for encouraging behaviour change based strategies to help people stop
smoking. With lifestyle a government pri-
The importance of effective communication skills
ority, healthcare staff, including nurses,
How to set achievable goals need the knowledge and skills to deliver
brief behaviour change interventions.
Patient-centred communication
Author Nicola Davies is a health psychology NHS (Department of Health, 2010), empha- Good verbal and behavioural communica-
researcher at Health Psychology sises public health. It also places nurses at tion between patient and nurse is funda-
Consultancy, Shefford, Bedfordshire. the forefront of a policy to provide patients mental to behaviour change attempts and
Abstract Davies N (2011) Healthier with the information and support that outcomes (Robinson et al, 2008). Key com-
lifestyles: behaviour change. Nursing empowers them to take responsibility for munication skills in patient-centred care
Times; 107: 23, 20-23. their health and their lifestyle choices. include ascertaining reasons for accessing
Unhealthy lifestyle choices such as Other guidance identifies a key role for healthcare services, finding common
smoking and poor diet are significant and nurses and other frontline staff in helping ground, providing information and
preventable causes of long-term conditions. people to adopt and sustain healthier life- sharing decisions.
Nurses are well placed to encourage and styles (Royal College of Nursing, 2007). Researchers have identified verbal and
support patients to make healthy choices. Evidence suggests that patients would non-verbal activities that are associated
Through good communication, prefer lifestyle interventions to be deliv- with patients changing behaviour. These
collaboration and goal-setting, behaviour ered by nurses than doctors (Lock, 2004). are: empathy; reassurance; encourage-
change is possible. This article discusses ment; explanation; addressing patients
evidence for the best ways to initiate and Theories of health-related feelings and emotions; increased health
sustain behaviour change. behaviour change education; friendliness; listening; positive
T
Evidence on the cognitive, emotional and reinforcement; being receptive to patients
obacco, alcohol, physical inac- environmental factors that influence health- questions; and allowing the patients point
tivity and poor diet are among related behaviour is accumulating (Table 1). of view to guide the conversation (Beck et
the biggest contributors to most As a result, health professionals are being al, 2002).
preventable diseases. They are encouraged to target patients attitudes and By comparison, passive acceptance,
responsible for 42% of deaths and, together, beliefs to improve lifestyle choices. formal behaviour, antagonism, passive
account for at least 9.4bn in annual direct Factors influencing health behaviour rejection, high rates of biomedical ques-
costs to the NHS (Bernstein et al, 2010). can be explained using five theoretical tioning, interruptions, irritation, domi-
Low physical activity is the most preva- models: social cognitive theory; the trans- nance and a one-way flow of information
lent risk factor for long-term conditions, theoretical model; motivational inter- from the patient (information collection
with 95% of the adult population not viewing; self-determination theory; and without feedback) are associated with neg-
meeting the recommended minimum 30 social ecological theory (Table 2). ative patient outcomes (Beck et al, 2002).
minutes of moderate-intensity physical It has been shown that a better theoret- Health professionals have been found
activity five or more days a week (Troiano ical understanding of behaviour change to be poor at asking open direct questions
et al, 2008). techniques can improve the likelihood of such as How do you feel about? (Parle
These four lifestyle behaviours need to be health professionals being successful in et al, 1997). In general, they fear that asking
targeted to improve the health of the nation explaining communicating changes to these questions will open a can of worms
and maintain good-quality healthcare in patients (Powell and Thurston, 2008). and result in emotional reactions they
an overstretched NHS, as well as to improve Extensive work in health psychology cannot deal with, such as depression, fear
individuals health and quality of life. has identified techniques and strategies to or hostility (Parle et al, 1997).
Taking this into account, the white help people to adopt healthier lifestyles. Shortage of time is another reason why
paper, Equity and Excellence: Liberating the These have been used in the NHS Centre nurses may avoid behaviour change
points
resistance is an oppositional reaction to
lifestyle-related health any discussion of behaviour change.
behaviours
1 Preventable
lifestyle-related
illness costs the Attitudes Peoples views or judgements in relation to their
Successful motivational interviewing
requires consistency in several core com-
munication skills, tools and strategies
NHS billions of
health (Table3). It is collaborative, in that the nurse
pounds every year Beliefs Peoples opinions of their health works with patients, addressing their con-
2 Nurses have an
important role
in promoting and
Motivation
Intention
The process that drives health behaviours
A plan of action intended to affect ones health
cerns, and helping them to make progress.
The underlying principle is that patients are
the experts on their own lives and are gener-
supporting
Volition Making a conscious health-related choice ally better persuaded by their own reasons
healthier behaviour for changing behaviour than by others.
3 The most Planning Forming specific health-related aims and The approach supports patient
effective way objectives autonomy but patients cannot persuade
of changing Social support Psychological and emotional assistance from themselves of the need for behaviour
behaviour is friends and family change if they cannot accurately assess
collaborating with
Self-monitoring Ability to measure and assess ones own health their health status. This is where health
the patient baseline comparisons offer valuable guid-
4 Assessing
motivation can
help in tailoring
Social and material
environment
Modification of influences in the environment
that will benefit health
ance to nurses. These are reference points
people use to evaluate their health status
and determine whether they need to make
interventions any changes (Davies et al, 2008).
5 Setting goals
can boost
patient confidence
overcome difficulties in implementing
strategies and improve communication.
These do not always produce healthy
lifestyle choices, however. For example, a
person who smokes may evaluate their
and long-term Putting theory into practice health as good because they eat five pieces
success Motivational interviewing of fruit a day. In such an encounter, nurses
Motivational interviewing is a non- can use motivational interviewing tech-
confrontational way of raising the topic of niques to guide patients towards a more
techniques. With growing financial pres- lifestyle, so overcomes at least one of the realistic evaluation of their health.
sures, this problem is likely to increase. potential barriers to such discussions. Autonomy in decision-making is an
Despite these barriers, nurses are more It is an easy approach that helps to important component of motivational
likely to implement behaviour change improve the quality of the nurse-patient interviewing and crucial for the mainte-
techniques than other health professionals interaction. The strategy focuses on two nance of new, healthier behaviours. Many
(Laws et al, 2008). Knowledge of theory aspects of patients speech: change talk is health behaviour interventions fail
and evidence-based guidance can help when the patient indicates or discusses because they target the behaviour itself
Social cognitive theory (Bandura, 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 attempted change
Self-determination theory (Deci and The patients experiences of autonomy, competence and relatedness (the effort made to relate to others; feeling accepted by
Ryan, 1985) others; and experiencing satisfaction with the social world) are affected by autonomy, supportive healthcare environments,
individual differences in personality, and the intrinsic and extrinsic nature of the patients goals. When humans feel their
psychological needs are being supported, they tend to have better mental health, quality of life, and health-related outcomes such
as greater intake of fruit and vegetables, less smoking, and better adherence to healthcare advice
Social ecological theory The concept of a health-promoting environment whereby behaviour is described as a series of layers, where each layer affects the
(Bronfenbrenner, 1977) next level. The inner level represents the individual, which is surrounded by differing levels of environmental influences. For
example, the social environment of family, friends and workplace is embedded in 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 affect behaviour
Motivational interviewing (Miller and A person-centred, directive method for enhancing intrinsic motivation to change by exploring and resolving any ambivalence to
Rollnick, 2002) change. The technique is underpinned by a belief that patients are the experts on their own lives and that people are generally
better persuaded by their own reasons for behaviour change than by the reasons of others
table 3. Motivational interviewing skills and efficacy (Bandura, 1989), as this can influ-
strategies ence both the initiation and maintenance
of behaviour change.
Key skills Communication Tools and strategies Self-efficacy refers to confidence in ones
Express empathy Open-ended questions Setting the scene ability to achieve the desired behaviour
Develop discrepancy Affirmations Agreeing on the agenda change. Evidence suggests that individuals
Roll with resistance Reflective listening Exploring a typical day high in self-efficacy are more resilient when
Support self-efficacy Summaries to communicate Assessing confidence confronted by barriers or relapse. Someone
Resist the righting reflex understanding Exploring two possible futures with low self-efficacy, on the other hand, is
Understand the patients dilemma Looking back and looking forward more likely to give up after a setback.
Listen Exploring options Goal setting is the most effective method
Empower the patient Agreeing goals
of working towards increased self-efficacy
Agreeing a plan
(Knols et al, 2010). Importantly, goals need
to be realistic and achievable, as well as set
by the patient, not the nurse. Nurses can,
rather than the underlying attitudes that model, effective behaviour change inter- however, guide the process by promoting
drive it. By assessing motivation to change ventions need to be tailored to the stage of achievable goals, such as moderate rather
and identifying patients whose attitude is the individual. Action-oriented interven- than vigorous physical activity, or 10 min-
conducive to change, nurses can allocate tions are unlikely to produce successful utes of exercise three times throughout the
their time and resources wisely. Patients outcomes in people who are in the pre- day when 20 minutes in one go may seem
who are motivated to change may merely contemplation stage and have not yet too much. Realistic goal-setting is particu-
require information and a support system. acknowledged the need to change. larly important at the beginning of an
If they are not motivated to change, moti- This model illustrates if patients leave attempt to change behaviour as this is when
vational interviewing might instantly consultations having moved from pre-con- failure is more likely to reduce motivation.
change their attitude or raise questions templation to contemplation, they are one According to Bandura (1989), self-effi-
that potentially lead to future change. stage closer to change. Therefore, the goal cacy can be enhanced in four ways:
Patients who walks away with no com- for nurses is to provide the information and Mastery experiencing goal-related
mitment to change need not be perceived support needed to facilitate informed deci- success;
as failed attempts. By establishing their sion-making around health-related behav- Vicarious experience seeing someone
readiness to change and their motivation iours. Helping patients to recognise the succeeding at goals;
to change through a motivational inter- need to change will increase self-motiva- Verbal persuasion positive feedback;
viewing approach, nurses have identified tion and the likelihood of sustained change. Physiological feedback subjective
the best course of action. perceptions of physiological responses
Sometimes the best course of action is || |||| (for example, breathlessness after
to accept the patients resolve to continue
|| 95% exercise can be seen as a sign of a good
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QUICK
with unhealthy lifestyle choices, in the do not do enough workout or a sign of being unhealthy).
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FACT
knowledge that you have at the very least exercise Ashford et al (2010) suggest three strate-
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increased their health literacy so that they gies to enhance patient self-efficacy
can make informed lifestyle decisions. through goal-setting and achievement:
Self-efficacy Action planning (helping patients to
Readiness to change When patients are motivated and ready to commit to a date when they will initiate
The transtheoretical model, perhaps better change an unhealthy behaviour, evidence- behaviour change);
known as the stages of change model, based techniques can be used to help them Reinforcing (praising or encouraging
purports that individuals modify their to achieve their desired outcome. Of pri- behaviour change efforts);
behaviour through a series of five distinct mary concern should be the patients self- Instruction (demonstrating how a piece
stages from pre-contemplation to mainte-
nance (Prochaska et al, 1992). Some people
move through the stages, but most will
table 4. Ten processes of change
relapse and return to earlier stages. This
1. Consciousness raising Increasing information about unhealthy behaviours
pattern is repeated until behaviour change
attempts are successful or unsuccessful. 2. Self-re-evaluation Assessing personal feelings about unhealthy behaviours
There are 10 processes of change identi- 3. Self-liberation Committing to change
fied by Prochaska et al (1992) (Table 4). Of
these, helping relationships, conscious- 4. Counter-conditioning Replacing unhealthy behaviours with substitutes
ness-raising and self-liberation are con- 5. Stimulus control Avoiding stimuli that prompt unhealthy behaviours
sistently the top three ranked processes
regardless of the health behaviour being 6. Reinforcement management Self rewards or rewards from others for making changes
targeted. Helping relationships and con- 7. Helping relationships Being open and trusting with someone who cares
sciousness-raising are implicit within the
nurse-patient dynamic, and self-liberation 8. Dramatic relief Finding solutions to barriers
is something that nurses can help patients 9. Environmental re-evaluation Assessing how barriers affect physical environment
with through education and support.
According to the transtheoretical
10. Social liberation Increasing opportunities for healthier behaviours