Many long-term conditions can be prevented by simple lifestyle changes. Nurses can draw on a number of theories to help them support patients to change behaviour
In this article…
- Effective techniques for encouraging behaviour change
- The importance of effective communication skills
- How to set achievable goals
Nicola Davies is a health psychology researcher at Health Psychology Consultancy, Shefford, Bedfordshire.
Davies N (2011) Healthier lifestyles: behaviour change. Nursing Times; 107: 23, early online publication.
Unhealthy lifestyle choices such as smoking and poor diet are significant and preventable causes of long-term conditions. Nurses are well placed to encourage and support patients to make healthy choices. Through good communication, collaboration and goal-setting, behaviour change is possible. This article discusses evidence for the best ways to initiate and sustain behaviour change.
Keywords: Health lifestyle, Behaviour
- This article has been double-blind peer reviewed
Five key points
- Preventable lifestyle-related illness costs the NHS billions of pounds every year
- Nurses have an important role in promoting and supporting healthier behaviour
- The most effective method of encouraging behaviour change is to work in collaboration with the patient
- Assessing patient motivation can help tailor interventions to the individual
- Setting goals can boost patient confidence and long-term success
Tobacco, alcohol, physical inactivity and poor diet are among the biggest contributors to most preventable diseases. They are responsible for 42% of deaths and, together, account for at least £9.4bn in annual direct costs to the NHS (Bernstein et al, 2010).
Low physical activity is the most prevalent risk factor for long-term conditions, with 95% of the adult population not meeting the recommended minimum 30 minutes of moderate-intensity physical activity five or more days a week (Troiano et al, 2008).
These four lifestyle behaviours need to be targeted to improve the health of the nation and maintain good-quality healthcare in an overstretched NHS, as well as to improve individuals’ health and quality of life.
Taking this into account, the white paper, Equity and Excellence: Liberating the NHS (Department of Health, 2010), emphasises public health. It also places nurses at the forefront of a policy to provide patients with the information and support that empowers them to take responsibility for their health and their lifestyle choices.
Other guidance identifies a key role for nurses and other frontline staff in helping people to adopt and sustain healthier lifestyles (Royal College of Nursing, 2007). Evidence suggests that patients would prefer lifestyle interventions to be delivered by nurses than doctors (Lock, 2004).
Theories of health-related behaviour change
Evidence on the cognitive, emotional and environmental factors that influence health-related behaviour is accumulating (Table 1). As a result, health professionals are being encouraged to target patients’ attitudes and beliefs to improve lifestyle choices.
Factors influencing health behaviour can be explained using five theoretical models: social cognitive theory; the trans-theoretical model; motivational interviewing; self-determination theory; and social ecological theory (Table 2).
It has been shown that a better theoretical understanding of behaviour change techniques can improve the likelihood of health professionals being successful in explaining communicating changes to patients (Powell and Thurston, 2008).
Extensive work in health psychology has identified techniques and strategies to help people to adopt healthier lifestyles. These have been used in the NHS Centre for Smoking Cessation and Training programme (2010), which provides evidence-based strategies to help people stop smoking. With lifestyle a government priority, healthcare staff, including nurses, need the knowledge and skills to deliver brief behaviour change interventions.
Good verbal and behavioural communication between patient and nurse is fundamental to behaviour change attempts and outcomes (Robinson et al, 2008). Key communication skills in patient-centred care include ascertaining reasons for accessing healthcare services, finding common ground, providing information and sharing decisions.
Researchers have identified verbal and non-verbal activities that are associated with patients changing behaviour. These are: empathy; reassurance; encouragement; explanation; addressing patients’ feelings and emotions; increased health education; friendliness; listening; positive reinforcement; being receptive to patients’ questions; and allowing the patient’s point of view to guide the conversation (Beck et al, 2002).
By comparison, passive acceptance, formal behaviour, antagonism, passive rejection, high rates of biomedical questioning, interruptions, irritation, dominance and a one-way flow of information from the patient (information collection without feedback) are associated with negative patient outcomes (Beck et al, 2002).
Health professionals have been found to be poor at asking open direct questions such as “How do you feel about…?” (Parle et al, 1997). In general, they fear that asking these questions will “open a can of worms” and result in emotional reactions they cannot deal with, such as depression, fear or hostility (Parle et al, 1997).
Shortage of time is another reason why nurses may avoid behaviour change techniques. With growing financial pressures, this problem is likely to increase.
Despite these barriers, nurses are more likely to implement behaviour change techniques than other health professionals (Laws et al, 2008). Knowledge of theory and evidence-based guidance can help overcome difficulties in implementing strategies and improve communication.
Putting theory into practice
Motivational interviewing is a non-confrontational way of raising the topic of lifestyle, so overcomes at least one of the potential barriers to such discussions.
It is an easy approach that helps to improve the quality of the nurse-patient interaction. The strategy focuses on two aspects of patients’ speech: “change talk” is when the patient indicates or discusses desire and commitment to change; and “resistance” is an oppositional reaction to any discussion of behaviour change.
Successful motivational interviewing requires consistency in several core communication skills, tools and strategies (Table 3). It is collaborative, in that the nurse works with patients, addressing their concerns, and helping them to make progress. The underlying principle is that patients are the experts on their own lives and are generally better persuaded by their own reasons for changing behaviour than by others’.
The approach supports patient autonomy but patients cannot persuade themselves of the need for behaviour change if they cannot accurately assess their health status. This is where health baseline comparisons offer valuable guidance to nurses. These are reference points people use to evaluate their health status and determine whether they need to make any changes (Davies et al, 2008).
These do not always produce healthy lifestyle choices, however. For example, a person who smokes may evaluate 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.
Autonomy in decision-making is an important component of motivational interviewing and crucial for the maintenance of new, healthier behaviours. Many health behaviour interventions fail because they target the behaviour itself rather than the underlying attitudes that drive it. By assessing motivation to change and identifying patients whose attitude is conducive to change, nurses can allocate their time and resources wisely. Patients who are motivated to change may merely require information and a support system. If they are not motivated to change, motivational interviewing might instantly change their attitude or raise questions that potentially lead to future change.
Patients who walks away with no commitment to change need not be perceived as failed attempts. By establishing their readiness to change and their motivation to change through a motivational interviewing approach, nurses have identified the best 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.
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 from pre-contemplation to maintenance (Prochaska et al, 1992). Some people move through the stages, but most will relapse and return to earlier stages. This pattern is repeated until behaviour change attempts are successful or unsuccessful.
There are 10 processes of change identified by Prochaska et al (1992) (Table 4). Of these, helping relationships, consciousness-raising and self-liberation are consistently the top three ranked processes regardless of the health behaviour being targeted. Helping relationships and consciousness-raising are implicit within the nurse-patient dynamic, and self-liberation is something that nurses can help patients with through education and support.
According to the transtheoretical model, effective behaviour change interventions need to be tailored to the stage of the individual. 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 if patients leave consultations having moved from pre-contemplation to contemplation, they are one stage closer to change. Therefore, the goal for nurses is to provide the information and support needed to facilitate informed decision-making around health-related behaviours. Helping patients to recognise the need to change will increase self-motivation and the likelihood of sustained change.
When patients are motivated and ready to change an unhealthy behaviour, evidence-based techniques can be used to help them to achieve their desired outcome. Of primary concern should be the patient’s self-efficacy (Bandura, 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.
Goal setting is the most effective method of working towards increased self-efficacy (Knols et al, 2010). Importantly, goals need to be realistic and achievable, as well as set by the patient, not the nurse. Nurses can, however, guide the process by promoting achievable goals, such as moderate rather than vigorous physical activity, or 10 minutes of exercise three times throughout the day when 20 minutes in one go may seem too much. Realistic goal-setting is particularly important at the beginning of an attempt to change behaviour as this is when failure is more likely to reduce motivation.
According to Bandura (1989), self-efficacy can be enhanced in four ways:
- Mastery – experiencing goal-related success;
- Vicarious experience – seeing someone succeeding at goals;
- Verbal persuasion – positive feedback;
- Physiological feedback – subjective perceptions of physiological responses (for example, breathlessness after exercise can be seen as a sign of a good workout or a sign of being unhealthy).
Ashford et al (2010) suggest three strategies to enhance patient self-efficacy through goal-setting and achievement:
- Action planning (helping patients to commit to a date when they will initiate behaviour change);
- Reinforcing (praising or encouraging behaviour change efforts);
- Instruction (demonstrating how a piece of exercise equipment is used, or providing guidance on healthier cooking methods).
These strategies can be combined so that patients are helped to set realistic goals that can be achieved via a written action plan with time limits, instructions and a reward system. It is important that goals are measurable, so that it is clear when they have been achieved.
An example of a measurable goal is to achieve 20 minutes of walking three days a week. Efforts to achieve this goal could be rewarded with words of encouragement, while actually achieving the goal could be self-rewarded with, for example, a new dress or a meal out with friends. Change techniques are summarised in Table 5.
The 5 A’s framework
The 5 A’s approach, as recommended by the Canadian task force on preventive healthcare, provides a feasible framework for behaviour change interactions. They are: assess; advise; agree; assist; and arrange (tinyurl.com/US-preventative-task-force).
The first stage is to assess patients’ awareness of any unhealthy behaviours, as well as their motivation and readiness to change. Advice and information can then be provided on the risks and benefits associated with a health behaviour as well as on support services that can help the patient.
Once patients have 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. Arranging follow-up provides the opportunity for reassessment as well as to monitor progress and adjust action plans accordingly. Throughout all stages, motivational interviewing skills can be used to engage patients via open-ended questions that enhance their autonomy.
Research suggests that long-term behaviour change is unlikely to be sustained without the involvement of health professionals (Prochaska et al, 1992).
By taking an interest in patients’ lifestyle and communicating with them over behaviour change, nurses are endorsing a healthy lifestyle, enhancing patient health and wellbeing, and taking primary and secondary preventive measures.
To deliver quality outcomes for patients and healthcare services, frontline staff need to work towards creating informed patients who have goals and a plan to improve their health. Nurses are well placed to deliver this vision through information provision, support, and other evidence-based techniques.
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