Helping clients move towards health change: encouraging individual clients to make lifestyle changes is not easy. Using the "stages of change" model can be a useful tool for nurses.

I was taken aback recently while preparing a lecture for my students on nurses and health promotion/education with individuals. The author whose work I was perusing suggested that, when nurses worked with clients, they were merely participating in "one-off reductionist information giving exercises". (1) By this I assume the author meant nurses merely identified the problem (as they perceived it) of their client, and attempted to fix that one thing--a bit like being a mechanic fixing an engine part when it breaks down.

I have a particular interest in individual health promotion and currently work with a number of individuals and groups on a voluntary basis. This comment made me pause and catch my breath. The week before I had told my students that nurses (42,000 of us in New Zealand), of all health professionals, are best able to adopt an holistic approach when dealing with clients--hardly a mechanical approach.

The main focus of my lecture was American psychotherapist James Prochaska's stages of change theory. (2) This model deals with individuals and how they move towards change. I was challenged to examine just how extensively I used this model in my own practice.

Prochaska, along with fellow psychotherapist Carlo DiClemente, developed his model in the 1970s in response to the death of his father from alcoholism and depression. Prochaska was unable to understand why his father distrusted psychotherapy. (2) He never found his answer in the multitude of theories that cluttered the field of psychotherapy, so he embarked on a thorough analysis of the literature, conducted his own research and came up with his own theory. Prochaska argued that the hundreds of therapeutic theories out there could be summarised in a few critical principles which he called "processes of change" At the end of the day, these processes are any activities initiated to help someone modify their thinking, feeling or behaviours (see figure 1).

Figure 1

PROCHASKA'S STAGES FOR CHANGE

1) Precontemplation: The individual is not even considering changing his/her unhealthy behaviour, at least not in the next six months.

2) Contemplation: The individual is considering changing but not in the immediate future--maybe within the next six months.

3) Planning or preparation: The individual is planning to change, maybe within the next month. They may have already started making small changes.

4) Action: The immediate period following the trial and adoption of the recommended behaviour and cessation of unhealthy behaviour (usually over a period of months).

5) Maintenance: The period following the action stage until the unhealthy behaviour in fully extinguished. This involves continuation and stabitisation of the change.

6) Termination: When the problem behaviour is completely eliminated. (3)

Seeing the stages set out clearly made me wonder whether I had really made a conscious effort to use this model. The answer was "yes" and "no". When Prochaska's model first came into use, it was hugely popular, sweeping all before it in the field of health promotion. At the time I was running smoking cessation programmes. We immediately started targeting our clients at the contemplation, planning and preparation stage by asking them to choose a date when they would stop smoking and reflect on the changes they would make. This was even before the programme had got properly underway!

While I am by no means an expert, here are some examples showing how I have used the stages in recent contacts with clients.

Precontemplation: About six months ago I began working with an obese man named *Bill. Bill's brother *Ben also needed some guidance with weight toss, so I asked him if he would be interested in coming to Bill's sessions with me. "No, not interested," he retorted. My gentle persuasion only hardened his resolve to have nothing to do with me or what I had to offer. I then said to him; "look Ben, think about it and T will talk with you again tater." "OK", he replied.

Contemplation: I saw Ben a few months tater. "Not interested," he said, "but I'm thinking about it." That was like music to my ears for I knew he had now moved from pre-contemplation to contemplation.

Planning or preparation: About three months tater, when I arrived at Bill's home, I noticed Ben was seated at the table wanting to join our sessions. He had obviously reached the preparation stage. Ben is not the most enthusiastic person I have dealt with. Nevertheless I am glad to say he has really embraced change and lost a significant amount of weight.

Action: During this phase, we have been able to implement numerous lifestyle changes that are helping Ben achieve his goals and reach his desired weight. These have included keeping a diary of his activities and making small, simple, but significant changes.

Maintenance: Ben is continuing to keep a diary of his activities and together we are evaluating the effectiveness of changes he has made.

Termination: I doubt anyone attempting to lose weight would ever claim to have reached the termination stage. However, if the lifestyle principles they have adopted become part of their daily lives, then there is certainly less risk of them falling back into their pre weight loss days.

New smoking cessation group

A short time ago, I initiated a new smoking cessation group. In all, 11 people had agreed to meet me. I scheduled a meeting for the next week and told them that, for the next seven days, they should prepare themselves to become non-smokers. We met for an hour or two and then they left, armed with the knowledge they needed to stop smoking. A week later I caught up with them, to find only one person had not smoked during that time. This person was the very one I thought would not succeed. I analysed why I had got it wrong in this instance. I concluded that only one person in the group was in the planning or preparation stage. This person had, in the previous few weeks, already been making small changes, so when we met she was ready to stop. At least three participants were in the precontemplation stage--they were just not interested. I should have been able to work that out from the body language. Two of the three demonstrated clearly they were only there because their wives had made them come. Five were in the contemplation stage. Yes, they wanted to be non-smokers but not in the immediate future. I am happy to say that since then, all but one has stopped smoking and this person is now in the planning or preparation stage.

Not long ago *Tom asked me if I would help him lose weight. I was pleased to see he had been thinking seriously about this for some time and, on our initial meeting, I found he had already started making small changes. He was dearly in the planning or preparation stage.

While it is preferable to start with a willing client, this may not always be the case. However, nurses should not be discouraged by our clients' apparent unwillingness to listen to advice. Subtle persuasion can be a powerful tool. A seed sown in the precontemplation period will often bear fruit and help people move to the planning stage. If we have played our part, we must never think our initial efforts have ended in failure.

Using a common sense approach can be fun as well Tom and I were discussing ways he could include more exercise into his lifestyle. "Do you like walking?" I asked. "It's alright," he said. "Then how fast do you walk?" "I dawdle," he said. "Do you think you could walk a bit faster?" "No," he said, "I like dawdling". Here was an immediate challenge. After probing his reluctance to stride out during exercise, I discovered he had an underlying heart condition and was afraid that, if he increased his walking speed, he might have another problem on his hands. I encouraged him to talk this over with his doctor on his visit the following day. I am pleased to say Tom now dawdles for two power poles and walks briskly for the next two.

Increasing the range of exercise

I felt *John, another of my clients, would benefit from doing more exercise. He walks but I felt other forms of exercise could also be helpful. "John, do you have a big backyard?" I asked. "Yes, I am just cleaning it up at the moment," he said. "Good, why don't you put a garden in?" "Oh no, I don't like gardening". "You know gardening is one of the best exercises you can do," I said. I could see John was not going to budge, so I said: "Why don't you plant a vegetable and flower garden in the spring? That will give you plenty of time to plan for it."

I could see a moment of contemplation cross his face. "Welt, I'll think about it," he said. After a couple more positive conversations, I believe John will be looking forward to eating from the fruits of his garden next summer, along with further health improvements.

* Steve is another client needing to lose weight. For some time I have been trying to get Steve to walk more. Finally I felt I had been making progress. "Steve, how is your waking going?" "Great," he said. "I am now walking to the Warehouse". "Wow, you are going well," I said, "That's a tong way". "Yes," he said, "it is."

After more gentle coaxing, Steve revealed he was actually driving to the Warehouse and walking around once he got there. For him it was a compromise, not the one I wanted but one that suited him. We finally agreed that walking briskly around the school grounds and the football fields adjacent to his home would be far better than his foray to the Warehouse. He would also save money and petrol.

Working with individuals is not easy. It can take time and effort. Nevertheless, the health benefits are too great to ignore. There are many things we need to consider. The stages of change model can be a useful tool to bring about change in our clients. It gives our clients the opportunity to contemplate change. It gives us an opportunity to be part of the change process. Nurses don't have to feel we have failed our clients if we can't get them to change during our initial contact with them. Chances are, they will begin acting on our advice before we know it.

This article was reviewed by Kai Tiaki Nursing New Zealand's practice article review committee in June 2007.

Reference

(1) Whitehead, O. Health education, behavioural change and society psychology: nursing's contribution to health promotion? Journal of Advanced Education; 34: 6, 822-832.

(2) Prochaska, J. O. & DiClemente, C. C. (1984) Toward an integrative model of change. Journal of Consulting and Clinical Psychology, 51, 390-395.

(3) Rankin, SH, Stallings, KD & London, F. (2005) Patient Education in Health and Illness. Sydney: Lippincott Williams and Wilkins.

* Names and details of clients have been changed to protect confidentiality.

Wayne Bradshaw, RN, DipTchg (Nsg), BEd (Nsg), MPubHlth, is a lecturer at the Waikato Institute of Technotogy's school of health. He is studying obesity for his doctorate in public health through Curtin University, Australia.