Throughout your nursing career, you’ve probably cared for more than a few patients who needed to make health-behavior changes but seemed to lack the motivation. These patients come in various forms—from the one with uncontrolled diabetes who refuses to check her blood glucose to the one recovering from a myocardial infarction who won’t reduce his sodium intake or start an exercise regimen. Patients like these can frustrate caregivers. Many eventually need to be readmitted to the hospital, at least in part because they refused to make a positive change.
Motivating patients to change their health behavior requires extensive education. But with limited time for patient teaching during the typical nursing shift, how do you squeeze in this health-promoting intervention? And when you do have an opportunity to teach, why are some patients unreceptive? How can you make your teaching more effective?
This article describes how to use the transtheoretical model (TTM) of behavior change to gauge your patient’s readiness to change, devise appropriate interventions, and help put an end to frustrating education sessions that fail to bring positive results.
Stages of the TTM
Developed by James Prochaska and colleagues in 1977, the TTM proposes that health-behavior change doesn’t stem from a single decision to become healthier but occurs as a series of stages over time—precontemplation, contemplation, preparation, action, maintenance, and termination. (Some researchers and clinicians omit the last stage, termination, when using the model in clinical applications; patients in this stage have reached maximum self-efficacy and no longer feel temptations that can hinder successful health-behavior change.)
Analyzing the pros and cons
Other important components of TTM include weighing the pros and cons of making a change and the concept of self-efficacy. Any decision to make a health-behavior change requires one to weigh the pros and cons of making it. This process is individualized, based on the person’s current knowledge level, or stage.
- Patients who lack knowledge about their disease typically are in the precontemplation stage. During this stage, patients perceive that the cons (drawbacks) of making the change outweigh the pros (benefits). Without a planned intervention, these patients may lack the motivation to learn about their disease and make prescribed health-behavior changes.
- In the contemplation stage, the pros and cons of making the change reach a balance. Nurses should use motivational interviewing techniques that highlight the benefits of making the change while minimizing perceived barriers to it.
- During the preparation stage, the pros of making the change start to outweigh the cons. This perception persists throughout the remaining stages.
- During the action stage, the patient perceives a high enough level of pros and a low enough level of cons to make the needed health-behavior change.
- A patient in the maintenance stage strives to prevent relapse and has become more confident in his or her ability to continue the health-behavior change.
When working to promote a health-behavior change, consider the patient’s self-efficacy. As conceptualized by psychologist Albert Bandura, self-efficacy refers to an internal confidence that allows a person to believe he or she can cope with high-risk
situations, such as a difficult health-behavior change, without relapsing into previous poor behaviors.
If you’ve struggled to educate and motivate patients to make health-behavior changes, perhaps your interventions weren’t tailored to the patient’s stage of readiness for change. Because the TTM is patient-centered, it helps nurses choose appropriate stage-based interventions that meet patients at their current readiness stage. If you’re not sure of your patient’s stage, you can use a stage-based questionnaire. (See Assessing your patient’s readiness to change by clicking the PDF icon above.)
The TTM framework includes 10 processes of change—
specific interventions to use when working with patients. Examples include self-reevaluation, environmental reevaluation, and stimulus control. Using stage-based interventions based on these processes enhances patient self-efficacy and motivation to change. (See Matching interventions with readiness stages by clicking the PDF icon above.)
Some of the most challenging patients to motivate toward health-behavior changes are those in the precontemplation stage. Many nurses label these patients resistant to change or noncompliant—but these labels can harm patients if you don’t keep searching for ways to connect with them. (Inevitably, though, you’ll encounter some patients whom you can’t motivate to make a change.)
Be sure to set realistic goals for patients. A practical goal for a nursing intervention is to help a patient progress one stage closer to the desired change. Research shows patients improve more readily when nurses focus on working through each stage individually instead of jumping right to the action or maintenance stage. Also, inform patients they will face various temptations that can pull them back toward previous unhealthy behaviors throughout the behavior-change process.
Using the TTM as a framework can help you better understand the process patients go through as they increase their readiness to make health-behavior changes. Only by understanding patients’ intent to change a behavior and selecting appropriate stage-based interventions can you enhance their choices about healthy behaviors.
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Prochaska JO, Johnson S, Lee P. The transtheoretical model of behavior change. In: Shumaker SA, Ockene JK, Riekert KA, eds. The Handbook of Health Behavior Change. 3rd ed. New York, NY: Springer Publishing; 2009:59-84.
Prochaska JO, Velicer WF. The transtheoretical model of health behavior change. Am J Health Promot. 1997;12(1):38-48.
Jennifer M. Barrow is a clinical assistant professor of nursing at McNeese State University in Lake Charles, Louisiana.