2.7 Behaviorial Change

After identifying modifiable risk factors, nurses encourage clients to reduce their risk for developing disease by making behavioral changes. It is helpful for nurses to understand human behavior as it relates to change. The Transtheoretical Model of Change describes the stages of change that clients must work through as they consider and implement behavior changes. The behavior change process occurs as clients transition through five changes of precontemplation, contemplation, preparation, action, and maintenance.^[1] See Figure 2.13^[2] for an illustration of the Transtheoretical Model of Change.

The Transtheoretical Model of Change states that when making behavioral changes, individuals pass through each stage at a varying pace. This pace is influenced by the type of behavior being changed, the environment, and the individual themselves. No stage is subject to any particular timeline; stages can last from as little as one hour to as long as a lifetime. Despite being displayed as a linear model, behavioral change is often nonlinear; progression and regression are common in stages of change. People may move forward, backward, and slide back and forth between stages in a complex and dynamic way. People do not, however, skip any stages and must move through this general sequence when changing behavior.

The Transtheoretical Model of Change indicates that people at different stages of change will be motivated by different messages. For example, a smoker in the precontemplation stage needs different information to move to the contemplation stage compared to a former smoker in the action stage to move to the maintenance stage. It is vital for nurses to use therapeutic communication and interventions that match an individual’s stage of change. Each stage is further discussed in the following subsections.

Precontemplation

During the precontemplation stage, clients see no need to find a solution to a problem because they are unaware of a problem or lack insight into the consequences of their lifestyle choices and/or behavior. While in this stage, individuals will defend their behavior and may become defensive when faced by efforts to pressure them to change.^[3]

Clients in this stage may be labeled by others as “resistant,” “unmotivated,” “unready,” or “unwilling to change.” They have no intention of making a change in the next six months and may make comments such as, “I don’t see a problem with what I’m doing, so there’s no reason to change anything.” Nurses providing health teaching and health promotion to individuals in the precontemplation stage often set goals related to raising the client’s consciousness about the problem and/or risk(s) of their lifestyle choices.^[4]

Contemplation

During the contemplation stage, the client is aware of and acknowledges the risks related to their lifestyle choices and/or behaviors. They are considering making a behavioral change but are uncertain if the problem or behavior is worthy of correction. Therefore, they have no commitment to taking the necessary steps toward change. The ambivalence that occurs in this stage can cause people to remain stuck in the contemplation stage for six or more months. In general, people in this stage are open to receiving information regarding their problems or risky behaviors and are interested in finding solutions to correct them. They may make comments such as, “I know I have a problem, and I think I should do something about it.”^[5]

Nurses providing health teaching to clients in the contemplation stage can use motivational interviewing techniques that highlight the benefits of making the change while minimizing perceived barriers to it.^[6] Motivational interviewing is further discussed later in this section.

Preparation

During the preparation stage, the client acknowledges that a behavior or risk is problematic and can make a commitment to correct it in the next 30 days. In this stage, the individual is aware that the positive aspects of change outweigh the negative and is actively looking for information to help them make a change. It is common for people in this stage to make comments such as, “Smoking is such a bad habit. I’ve been reading about different ways to quit, and even though I haven’t totally quit yet, I am smoking less than I did before.” It is vital for nurses to provide essential health-related information during this stage.^[7]

In this stage, insufficient planning can result in challenges, which may lead to relapse. For example, smokers in the preparation stage who plan to quit smoking but neglect to buy nicotine replacement like nicotine gum or patches may experience relapse.

Action

During the action stage, individuals are actively involved in changing their behavior and are open to receiving assistance from others. People in this stage believe they have the personal willpower to take on the process of change. Short-term positive reinforcement can help keep individuals motivated to continue to change, as well as plan how to overcome potential challenges on their journey to behavioral change.^[8]

While in this stage, people gain confidence as they believe they have the willpower to continue on the journey of change. They continue to review the importance of the behavioral change while evaluating their commitment to themselves. An example of a statement made by a client in the action stage would be, “It’s easy to say you’ll quit smoking, but I’m doing something about it. I haven’t smoked a cigarette in four months.” During this stage, nurses provide assistance and positive reinforcement during health teaching and health promotion interventions to sustain the client’s motivation.^[9]

Nurses help clients plan strategies to succeed in the behavior change, such as adopting alternative behaviors; avoiding the people, places, and situations that tempt them to participate in the behavior (such as bars); using stress management and methods to control their mood (e.g., exercise and mindfulness practices); and online grocery shopping to avoid buying (e.g., cigarette purchases in the store). Additionally, clients should be encouraged to reward themselves for each positive step taken (e.g., putting money that would have been spent on smoking into an account toward a positive goal or celebrating the anniversary of quitting each week, month, and year). Clients should also be encouraged to remind themselves of their accomplishments by journaling their efforts, experiences, and progress. Action is often the emphasis in treatment programs by teaching, training, and practicing new skills. A person in the action stage develops specific skills and behaviors to substitute for old, problematic behaviors as they consciously act to implement new behaviors.^[10]

Maintenance

Individuals in the maintenance stage exhibit total abstinence from the changed behavior and also have the ability to avoid temptations to return to the previous behavior. In this stage, individuals can remind themselves of the progress they have made, which helps reinforce the changes in behavior. Thoughts of returning to the previous behavior may arise, but the individual is able to resist temptations to do so due to proper planning and positive changes. For example, in this stage, someone who used to smoke has not only quit smoking but is easily able to maintain that status.^[11]

During the maintenance stage, nurses focus on helping the client continue their new behavior. As clients progress through this stage, they become more confident in their ability to sustain the positive lifestyle changes. Typically, people remain in this stage anywhere between six months to five years to maintain successful change. For example, a longitudinal study on smoking cessation showed that after 12 months of abstinence, 43% of people returned to their smoking habit. However, after reaching the five-year mark of abstinence, their risk for relapse dropped to 7%.^[12]

Clients in the maintenance stage require support as they reevaluate their reasons for change, acknowledge the success they’ve made thus far, consider the potential triggers for relapse, and create contingency plans to try and avoid relapse.^[13]

Relapse

Relapse occurs when an individual returns to the former problematic behavior, such as smoking, drinking excessively, or misusing other substances. Relapse is not a stage but can occur at any stage during the process. Relapse can be avoided with proper support networks and plans to prevent relapse. If relapse occurs, appropriate interventions can help individuals successfully return to the stages of change. Nurses can educate on and encourage use of community resources, medications, and provide support.^[14]

Motivational Interviewing

Motivational interviewing (MI) is a therapeutic communication technique used to elicit and emphasize a client’s personal motivation for modifying their behavior to promote health. It is especially helpful to use for clients in the contemplation stage of change. MI has been effectively used regarding several health issues such as smoking cessation, diabetes self-management, and abstinence from alcohol and other substances.^[15]

Motivational interviewing is a collaborative partnership between nurses and clients that is focused on client-centered care, autonomy, and personal responsibility. It is a technique that explores a client’s motivation, confidence, and roadblocks to change. During motivational interviewing, nurses pose questions, actively listen to client responses, and focus on where the client is now with a current health behavior and where they want to be in the future.^[16]

Motivational interviewing uses these principles^[17]:

• Expressing empathy. Use reflective listening to convey acceptance and a nonjudgmental attitude. Rephrase client comments to convey active listening and let clients know they are being heard.
• Highlighting discrepancies. Help clients become aware of the gap between their current behaviors and their values and goals. Present objective information that highlights the consequences of continuing their current behaviors to motivate them to change their behavior.
• Adjusting to resistance. Adjust to a client’s resistance and do not argue. The client may demonstrate resistance by avoiding eye contact, becoming defensive, interrupting, or seeming distracted by looking at their watch or cell phone. Arguing can place the client on the defensive and in a position of arguing against the change. Focus on validating the client’s feelings.
• Understanding motivations. Uncover a client’s personal reasons for making behavioral changes and build on them.
• Supporting self-efficacy. Encourage the client’s optimistic belief in the prospect of change and encourage them to commit to positive behavioral changes. Ask clients to elaborate on past successes to build self-confidence and support self-efficacy.
• Resisting the reflex to provide advice. Avoid imposing your own perspective and advice.