Healthier Lifestyle, Behaviour Change

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Healthier lifestyles:behaviour change

Many long-term conditions can be prevented by simple lifestyle changes. Nurses candraw on a number of theories to help them support patients to change behaviour

Author Nicola Davies is a health psychology

researcher at Health Psychology

Consultancy, Sheord, Bedfordshire.

Abstract Davies N (2011) Healthier

lifestyles: behaviour change. Nursing

Times; 107: 23, 20-23.

Unhealthy lifestyle choices such as

smoking and poor diet are signicant 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.

T

obacco, alcohol, physical inac-tivity and poor diet are among

the biggest contributors to mostpreventable diseases. They are

responsible for 42% of deaths and, together,account for at least 9.4bn in annual directcosts to the NHS (Bernstein et al, 2010).

Low physical activity is the most preva-lent risk factor for long-term conditions,

with 95% of the adult population notmeeting the recommended minimum 30minutes of moderate-intensity physicalactivity ve or more days a week (Troianoet al, 2008).

These four lifestyle behaviours need to betargeted to improve the health of the nationand maintain good-quality healthcare inan overstretched NHS, as well as to improveindividuals health and quality of life.

Taking this into account, the whitepaper, Equity and Excellence: Liberating the

Nursing PracticeDiscussionLifestyle change

Keywords:Health lifestyle / BehaviourThis article has been double-blind

peer reviewed

This article... Eective techniques for encouraging behaviour change The importance of eective communication skills

How to set achievable goals

NHS (Department of Health, 2010), empha-sises public health. It also places nurses atthe forefront of a policy to provide patients

with the information and support thatempowers them to take responsibility fortheir health and their lifestyle choices.

Other guidance identies a key role fornurses and other frontline staff in helpingpeople to adopt and sustain healthier life-styles (Royal College of Nursing, 2007).Evidence suggests that patients wouldprefer lifestyle interventions to be deliv-ered by nurses than doctors (Lock, 2004).

Theories of health-relatedbehaviour changeEvidence on the cognitive, emotional andenvironmental factors that inuence health-related behaviour is accumulating (Table 1).

As a result, health professionals are beingencouraged to target patients attitudes and

beliefs to improve lifestyle choices.Factors inuencing health behaviour

can be explained using ve theoreticalmodels: social cognitive theory; the trans-theoretical model; motivational inter-

viewing; self-determination theory; andsocial ecological theory (Table 2).

It has been shown that a better theoret-ical understanding of behaviour changetechniques can improve the likelihood ofhealth professionals being successful inexplaining communicating changes topatients (Powell and Thurston, 2008).

Extensive work in health psychologyhas identied techniques and strategies tohelp people to adopt healthier lifestyles.These have been used in the NHS Centre

for Smoking Cessation and Training pro-

gramme (2010), which provides evidence-based strategies to help people stopsmoking. With lifestyle a government pri-ority, healthcare staff, including nurses,need the knowledge and skills to deliver

brief behaviour change interventions.

Patient-centred communicationGood verbal and behavioural communica-tion between patient and nurse is funda-mental to behaviour change attempts andoutcomes (Robinson et al, 2008). Key com-munication skills in patient-centred careinclude ascertaining reasons for accessinghealthcare services, nding commonground, providing information andsharing decisions.

Researchers have identied verbal andnon-verbal activities that are associated

with patients changing behaviour. Theseare: empathy; reassurance; encourage-ment; explanation; addressing patientsfeelings and emotions; increased healtheducation; friendliness; listening; positivereinforcement; being receptive to patientsquestions; and allowing the patients pointof view to guide the conversation (Beck et

al, 2002).By comparison, passive acceptance,

formal behaviour, antagonism, passiverejection, high rates of biomedical ques-tioning, interruptions, irritation, domi-nance and a one-way ow of informationfrom the patient (information collection

without feedback) are associated with neg-ative patient outcomes (Beck et al, 2002).

Health professionals have been foundto be poor at asking open direct questionssuch as How do you feel about? (Parleet al, 1997). In general, they fear that askingthese questions will open a can of wormsand result in emotional reactions theycannot deal with, such as depression, fearor hostility (Parle et al, 1997).

Shortage of time is another reason whynurses may avoid behaviour change

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desire and commitment to change; andresistance is an oppositional reaction toany discussion of behaviour change.

Successful motivational interviewingrequires consistency in several core com-munication skills, tools and strategies(Table 3). It is collaborative, in that the nurse

works with patients, addressing their con-cerns, and helping them to make progress.The underlying principle is that patients arethe experts on their own lives and are gener-ally better persuaded by their own reasonsfor changing behaviour than by others.

The approach supports patientautonomy but patients cannot persuadethemselves of the need for behaviourchange if they cannot accurately assess

their health status. This is where healthbaseline comparisons offer valuable guid-ance to nurses. These are reference pointspeople use to evaluate their health statusand determine whether they need to makeany changes (Davies et al, 2008).

These do not always produce healthylifestyle choices, however. For example, aperson who smokes may evaluate theirhealth as good because they eat ve piecesof fruit a day. In such an encounter, nursescan use motivational interviewing tech-niques to guide patients towards a morerealistic evaluation of their health.

Autonomy in decision-making is animportant component of motivationalinterviewing and crucial for the mainte-nance of new, healthier behaviours. Manyhealth behaviour interventions fail

because they target the behaviour itself

5 keypoints

1Preventable

lifestyle-related

illness costs the

NHS billions of

pounds every year

2Nurses have an

important role

in promoting and

supporting

healthier behaviour

3The most

eective way

of changing

behaviour is

collaborating withthe patient

4Assessing

motivation can

help in tailoring

interventions

5Setting goals

can boost

patient condence

and long-term

success

www.nursingtimes.net / Vol 107 No 23 /Nursing Times 14.06.11 21

Table 1. FATS NFENNFESTE-EATE HEATHEHAS

Attitudes Peoples views or judgements in relation to theirhealth

Beliefs Peoples opinions of their health

Motivation The process that drives health behaviours

Intention A plan of action intended to affect ones health

Volition Making a conscious health-related choice

Planning Forming specific health-related aims andobjectives

Social support Psychological and emotional assistance fromfriends and family

S el f-m on itor in g Abil ity to mea su re an d a ss es s on es ow n h ea lt h

Social and materialenvironment

Modification of influences in the environmentthat will benefit health

Table 2. EHA HANE THEES AN ES

Transtheoretical model stages of change

(Prochaska et al, 1992)

Behaviour change is determined by readiness to change, which comprises five distinct stages:

Pre-contemplation: not yet acknowledging an unhealthy behaviour

Contemplation: acknowledging an unhealthy behaviour, but not yet ready to change

Preparation: getting ready to change

Action: changing the unhealthy behaviourMaintenance: remaining abstinent

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

Ryan, 1985)

The patients experiences of autonomy, competence and relatedness (the effort made to relate to others; feeling accepted by

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

(Bronfenbrenner, 1977)

The concept of a health-promoting environment whereby behaviour is described as a series of layers, where each layer affects the

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-ecologicalmodel affect behaviour

Motivational interviewing (Miller and

Rollnick, 2002)

A person-centred, directive method for enhancing intrinsic motivation to change by exploring and resolving any ambivalence to

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

overcome difculties in implementingstrategies and improve communication.

Putting theory into practiceMotivational interviewingMotivational interviewing is a non-confrontational way of raising the topic oflifestyle, so overcomes at least one of thepotential barriers to such discussions.

It is an easy approach that helps toimprove the quality of the nurse-patientinteraction. The strategy focuses on twoaspects of patients speech: change talk is

when the patient indicates or discusses

techniques. With growing nancial pres-sures, this problem is likely to increase.

Despite these barriers, nurses are morelikely to implement behaviour changetechniques than other health professionals(Laws et al, 2008). Knowledge of theoryand evidence-based guidance can help


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Nursing PracticeDiscussion

22 Nursing Times 14.06.11/ Vol 107 No 23 / www.nursingtimes.net

rather than the underlying attitudes thatdrive it. By assessing motivation to change

and identifying patients whose attitude isconducive to change, nurses can allocatetheir time and resources wisely. Patients

who are motivated to change may merelyrequire information and a support system.If they are not motivated to change, moti-

vational interviewing might instantlychange their attitude or raise questionsthat potentially lead to future change.

Patients who walks away with no com-mitment to change need not be perceivedas failed attempts. By establishing theirreadiness to change and their motivationto change through a motivational inter-

viewing approach, nurses have identiedthe best course of action.

Sometimes the best course of action isto accept the patients resolve to continue

with unhealthy lifestyle choices, in theknowledge that you have at the very leastincreased their health literacy so that theycan make informed lifestyle decisions.

Readiness to changeThe transtheoretical model, perhaps betterknown as the stages of change model,purports that individuals modify their

behaviour through a series of ve distinctstages from pre-contemplation to mainte-nance (Prochaska et al, 1992). Some peoplemove through the stages, but most willrelapse and return to earlier stages. Thispattern is repeated until behaviour changeattempts are successful or unsuccessful.

There are 10 processes of change identi-ed by Prochaska et al (1992) (Table 4). Ofthese, helping relationships, conscious-ness-raising and self-liberation are con-sistently the top three ranked processesregardless of the health behaviour beingtargeted. Helping relationships and con-sciousness-raising are implicit within thenurse-patient dynamic, and self-liberationis something that nurses can help patients

with through education and support.According to the transtheoretical

model, effective behaviour change inter-ventions need to be tailored to the stage of

the individual. Action-oriented interven-tions are unlikely to produce successfuloutcomes in people who are in the pre-contemplation stage and have not yetacknowledged the need to change.

This model illustrates if patients leaveconsultations having moved from pre-con-templation to contemplation, they are onestage closer to change. Therefore, the goalfor nurses is to provide the information andsupport needed to facilitate informed deci-sion-making around health-related behav-iours. Helping patients to recognise theneed to change will increase self-motiva-tion and the likelihood of sustained change.

Sel-efcacyWhen patients are motivated and ready tochange an unhealthy behaviour, evidence-

based techniques can be used to help themto achieve their desired outcome. Of pri-

mary concern should be the patients self-

efcacy (Bandura, 1989), as this can inu-ence both the initiation and maintenanceof behaviour change.

Self-efcacy refers to condence in onesability to achieve the desired behaviourchange. Evidence suggests that individualshigh in self-efcacy are more resilient whenconfronted by barriers or relapse. Someone

with low self-efcacy, on the other hand, ismore likely to give up after a setback.

Goal setting is the most effective methodof working towards increased self-efcacy(Knols et al, 2010). Importantly, goals needto be realistic and achievable, as well as set

by the patient, not the nurse. Nurses can,however, guide the process by promotingachievable goals, such as moderate rather

than vigorous physical activity, or 10 min-utes of exercise three times throughout theday when 20 minutes in one go may seemtoo much. Realistic goal-setting is particu-larly important at the beginning of anattempt to change behaviour as this is whenfailure is more likely to reduce motivation.

According to Bandura (1989), self-ef-cacy can be enhanced in four ways: Mastery experiencing goal-related

success; Vicarious experience seeing someone

succeeding at goals;

Verbal persuasion positive feedback;

Physiological feedback subjectiveperceptions of physiological responses(for example, breathlessness afterexercise can be seen as a sign of a good

workout or a sign of being unhealthy).Ashford et al (2010) suggest three strate-

gies to enhance patient self-efcacythrough goal-setting and achievement: Action planning (helping patients to

commit to a date when they will initiatebehaviour change);

Reinforcing (praising or encouragingbehaviour change efforts);

Instruction (demonstrating how a piece

Table 3. TATNA NTEEN SKS ANSTATEES

Key skills Communication Tools and strategies

Express empathy

Develop discrepancy

Roll with resistance

Support self-efficacy

Resist the righting reflex

Understand the patients dilemma

Listen

Empower the patient

Open-ended questions

Affirmations

Reflective listening

Summaries to communicate

understanding

Setting the scene

Agreeing on the agenda

Exploring a typical day

Assessing confidence

Exploring two possible futures

Looking back and looking forward

Exploring options

Agreeing goals

Agreeing a plan

Table 4. TEN PESSES F HANE

1. Consciousn ess raising Increasing information about unhealthy behaviours

2. Self-re-evaluation Assessing personal feelings about unhealthy behaviours

3. Self-liberation Committing to change

4. Counter-conditionin g Replacing unhealthy behaviours with substitutes

5. Stimulus control Avoiding stimuli that prompt unhealthy behaviours

6. Reinforcement management Self rewards or rewards from others for making changes

7. Helping relationships Being open and trusting with someone who cares8. Dramatic relief Finding solutions to barriers

9. Environmental re-evaluation Assessing how barriers affect physical environment

10. Social liberation Increasing opportunities for healthier behaviours

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www.nursingtimes.net / Vol 107 No 23 /Nursing Times 14.06.11 23

of exercise equipment is used, orproviding guidance on healthiercooking methods).

These strategies can be combined sothat patients are helped to set realisticgoals that can be achieved via a writtenaction plan with time limits, instructionsand a reward system. It is important thatgoals 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 aweek. Efforts to achieve this goal could berewarded with words of encouragement,

while actually achieving the goal could beself-rewarded with, for example, a newdress or a meal out with friends. Change

techniques are summarised in Table 5.

The 5 As rameworkThe 5 As approach, as recommended bythe Canadian task force on preventivehealthcare, provides a feasible frameworkfor behaviour change interactions. Theyare: assess; advise; agree; assist; and arrange(tinyurl.com/US-preventative-task-force).

The rst stage is to assess patientsawareness of any unhealthy behaviours, as

well as their motivation and readiness tochange. Advice and information can then

be provided on the risks and benets asso-ciated with a health behaviour as well as onsupport services that can help the patient.

Once patients have been fully informed,nurses can work collaboratively with themto agree a set of achievable, measurablegoals. Assistance can be provided in termsof skills development, barrier identica-tion, problem-solving and social support.Arranging follow-up provides the oppor-tunity for reassessment as well as to mon-itor progress and adjust action plansaccordingly. Throughout all stages, moti-

vational interviewing skills can be used to

engage patients via open-ended questionsthat enhance their autonomy.

onclusionResearch suggests that long-term behav-iour change is unlikely to be sustained

without the involvement of health profes-sionals (Prochaska et al, 1992).

By taking an interest in patients life-style and communicating with them over

behaviour change, nurses are endorsing ahealthy lifestyle, enhancing patient healthand wellbeing, and taking primary andsecondary preventive measures.

To deliver quality outcomes for patientsand healthcare services, frontline staffneed to work towards creating informedpatients who have goals and a plan toimprove their health. Nurses are well

placed to deliver this vision through infor-mation provision, support, and other evi-dence-based techniques. NT

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bOX 5. EHA HANE TEHNQES

Information provisionProviding general information about risks associated with

particular health choices, and the benefits and costs of behaviourchange action or inaction

Prompt intention formation Encouraging behaviour change decisions or goals

Barrier identification Identifying barriers and planning ways to overcome these barriers

Positive feedback Providing praise on behaviour change efforts and successes

Graded tasks Setting easy tasks, and increasing task difficulty until behaviourchange has been achieved

Model behaviour Showing an individual how to correctly perform particularbehaviours

Goal-setting Involving the detailed planning of what the person will do,including specific details on frequency, intensity, location,duration, and so on

Self-monitoring Asking the individual to keep a diary of specified behaviours

Prompts Teaching the use of prompts that can remind individuals toperform the behaviour

Behavioural contract Agreement of a contract specifying the behaviour to beperformed

Practice Prompting repetition of desired behaviours

Social comparisons Providing opportuniti es for individuals to compare themselveswith peers who have successfully mastered a specific behaviour

Social support Prompting consideration of how others could change theirbehaviour to offer the person help

Motivational interviewing Prompting the individual to provide self-motivating statements

Time management Helping the individual make time for the behaviour

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Healthier Lifestyle, Behaviour Change