Purpose: The aim of this essay is to enable students to demonstrate an understanding of and ability to apply the Transtheoretical Model of Change (Stages of Change Model) within an evidence based framework. In addition to this, students will identify components of Motivational Interviewing which could be utilised to assist with enabling a patient to change their health behaviours.
Task Alistair is a 55 year old male who has been admitted to the orthopaedic ward on which you are working for a total knee replacement (TKR). You have been allocated to care for him for the next 4 days as part of a trial of team nursing. He weighs 160kg and is due to have the TKR tomorrow. He states "I am bit worried about my health, I have been overweight for years and wonder if that is the reason my knee has given way". Using the Transtheoretical Model of Change and Motivational Interviewing techniques, describe how you could support Alistair through the Stages of Change cycle to maintenance. Utilise evidenced based literature to support your discussion.
The Transtheoretical Model of Change (TMC) is an integrated biopsychosocial model that intellectualizes the process of the intended action or objective in an orderly manner to change the behavior of a person from unhealthy to healthy. The TMC focuses exclusively on behavior change in a particular dimension to alter unhealthy lifestyles (Bully, Sánchez, Zabaleta-del-Olmo Pombo, & Grandes, 2015). The stages of TMC includes; precontemplation stage, contemplation stage, preparation stage, Action stage and Maintenance stage. Motivational interviewing is significant in ensuring that people undergo the steps of change efficiently. Motivational interviewing encompasses interpersonal processes to help patients change or continue certain behaviors. The principles of motivational interviewing are essential for empowering patients towards a particular practice. The principles of motivational interviewing include; showing and expressing empathy, developing and supporting discrepancy, supporting self-efficacy, dealing with resistance and promoting autonomy.
In the precontemplation stage, the patient has no intentions of acting due to fear or lack of knowledge about the surgery or appropriate therapy he/she is recommended to undergo. In this stage, people have a negative attitude towards changing their behaviors Alistair is worried about his health due to the Total Knee Replacement (TKR) operation he is going to undergo, and he is confused whether his overweight health status is responsible for his knee loss. Alistair's worries show that he is not much ready for the operation and he thinks if he could have altered the eating behaviors he could not be in such a painful situation. As the nurse in the orthopaedical ward, the advice I could offer to Alistair is to mobilize him on the importance of the operation because at this stage the patient had no other option than to undergo surgery. At a pre-contemplation stage, the patient requires only motivation because it is characterized by the patient's resistant, unready for help and unmotivated (Lee, Park, & Min, 2015).
It is at this stage where a person intends to change his or her attitude towards the correction of the behavior after six months. In this stage people begin to recognize that their action may result in problems in future, but though they still feel that undecided towards altering their behavior. In the contemplation stage, people weight between the advantages and disadvantages of that may result from the behavioral change. At this stage, encouragement to Alistair may mean some sense and can help him understand the importance of the knee replacement. I would now start showing Alistair the importance of changing his eating behaviors which accounted for his overweight (Knapen, Vancampfort, Moriën & Marchal, 2015).
Generally, at this stage people start to take simple steps towards changing their behavior and they also believe that if they change their lifestyles, it will lead to a future healthier life. In this stage, people are determined to take the actual action within a short period (one month). For the overweight individual at the preparation stage development plans for the action such as counselor consultation, joining the gym and also holding talks with physician obesity physicians. I could now start educating Alistair on the skills he would apply that will assist him to reduce weight. I could also encourage and motivate him to undergo the operation while showing him the ways that can fasten healing of the leg. Motivation would make him develop a positive attitude towards changing his behavior and make him not to lose hope due to his health status (Wadden, Butryn, Hong & Tsai, 2014).
In this stage, persons change their behavior and intend to continue with that behavior. Persons do exhibit the change by altering their old behavioral ways and adopting new and healthy ones. In the action stage, people make observable processes of behavioral change. I would advise Alister to reduce the amount of food he was taking per day and also educate him on the necessary foods which he should alter at. Some of the foods to encourage an overweight person to take includes; cholesterol free foods, foods with low content of fats and lipids. I would then encourage Alistair to engage more on physical exercise and with proper guidance which would help him reduce weight easily (Romain, Bernard, Hokayem, Gernigon & Avignon, 2016).
The maintenance stage involves a situation where a person has now sustained his or her behavioral change for more than six years. In this stage, the person intends to move forward with the current behavior. People at this stage are actively working to prevent deterioration to the earlier stages. My advice to Alistair at this stage is to encourage to ultimately adopt the current and new behavior such as moderate meals and never turn back to fatty foods. I would help Alistair keep more on physical exercise to maintain his health status. People who manage the new healthy behavior are more unlikely to or have no desire to return to the earlier unhealthy behaviors (Mastellos, Gunn, Felix, Car & Majeed, 2014).
Showing and expressing empathy toward the patients
The healthcare providers require to demonstrate and express compassion when dealing with the patients. As a nurse I would demonstrate empathy when discussing thoughts, life events and behaviors that patients engage to. By showing empathy rapport and trust is built which helps the patients to be more open in sharing their concerns, struggle and history. As in the case study, Alistair is overweight and a good rapport is required to help him in communicating effectively about the primary cause of the problem. This principle agrees with the fact that patients may be reluctant in sharing their information, especially at the start. Showing empathy is essential especially in the stage of precontemplation where a patient is not ready to take any action towards their health. Nurses need to be active and skillful when listening to what the patient is sharing (Barnes & Ivezaj, 2015).
During motivational interviewing clients justify for changing their behaviors, the nurses should not be viewed as if they are correct. Any perceived disagreement between the patients' current values, behaviors, and health status generates an internal tension that may require reasoning for the change. If time is limited, the best choice is asking patients why they might want a change and how they might achieve it instead of depending on telling the patient what they should do. For example, Alistair might be interested in practicing other weight loss techniques but the nurse should inform the patient about the importance of total knee replacement. Developing and supporting discrepancy is essential especially in the stage of contemplation where patients are getting ready to change their behaviors (Simpson et al, 2015).
When patients refuse to change their behaviors, a nurse does not have to confront the patients' resistance but rather should struggle with the patients to see the nurse's point of view. As discussion continues, as the nurse you should work in collaboration with the patient to help them examine and see different viewpoints and allow the patient to choose the viewpoint they want to stick to. When resistance occurs as the nurse, I will consider changing the tactic to the therapy talks (Copeland, McNamara, Kelson & Simpson, 2015). Alistair needs to know the importance of total knee replacement in losing weight since he is more overweight. Other methods of weight loss like physical exercise, eating food that do not have calories should be considered but because Alistair's knee has given away total knee replacement is the best option (Elwyn, Dehlendorf, Epstein, Marrin, White & Frosch, 2014).
The nurses have an obligation of ensuring that patients feel that they are capable of attaining the change they desire. This principle requires the nurse to point out and discuss previous life and behavioral successes that patients have achieved. Former and current skills and strengths patients possesses are discussed, it increases the patient's belief that change can be attained. Patients are ready to take actions to help address their problems (Christie & Channon, 2014). The nurse should encourage Alistair in taking the surgery for total knee replacement because it will assist him in losing weight. Supporting self-efficacy helps clients to act in changing their behaviors.
Nurses should demonstrate to their patients that the power to change comes from them and not the nurse. It helps in expressing to the patient that they are responsible for changing their behavior (Rutten, Meis, Hendriks, Hamers, Veenhof & Kremers, 2014). Nurses listen as patients develop action steps that they require in order to change their behaviors. The patient needs to maintain the behavior that they intend to change for a while. Alistair after the total knee surgery he requires to keep his weight for the knee to heal quickly. The behaviors that Alistair need to maintain in order to ensure effective weight loss include; regular physical exercise, eating foods with fewer fats to burn calories and joining programs like a gym that can help in losing weight.
Both the stages transtheoretical and motivational model of change are the aims of changing the behavior of a person from unhealthy to health behavior. The TMC and MI can help a person with entirely negative thoughts or attitudes through the sequential stages to alter and decide towards healthy lifestyles. A nurse should apply these stages of behavioral change when handling a patient with unhealthy nutritional lifestyles like in the case study where overweight is an issue for Alistair.
Barnes, R. D., & Ivezaj, V. (2015). A systematic review of motivational interviewing for weight loss among adults in primary care. Obesity reviews, 16(4), 304-318.
Bully, P., Sánchez, Á., Zabaleta-del-Olmo, E., Pombo, H., & Grandes, G. (2015). Evidence from interventions based on theoretical models for lifestyle modification (physical activity, diet, alcohol and tobacco use) in primary care settings: a systematic review. Preventive medicine, 76, S76-S93.
Christie, D., & Channon, S. (2014). The potential for motivational interviewing to improve outcomes in the management of diabetes and obesity in pediatric and adult populations: a clinical review. Diabetes, Obesity and Metabolism, 16(5), 381-387.
Copeland, L., McNamara, R., Kelson, M., & Simpson, S. (2015). Mechanisms of change within motivational interviewing in relation to health behaviors outcomes: a systematic review. Patient education and counseling, 98(4), 401-411.
Elwyn, G., Dehlendorf, C., Epstein, R. M., Marrin, K., White, J., & Frosch, D. L. (2014). Shared decision making and motivational interviewing: achieving patient-centered care across the spectrum of health care problems. The Annals of Family Medicine, 12(3), 270-275.
Knapen, J., Vancampfort, D., Moriën, Y., & Marchal, Y. (2015). Exercise therapy improves both mental and physical health in patients with major depression. Disability and rehabilitation, 37(16), 1490-1495.
Lee, J. Y., Park, H. A., & Min, Y. H. (2015). Transtheoretical model-based nursing intervention on lifestyle change: a review focused on intervention delivery methods. Asian nursing research, 9(2), 158-167.
Mastellos, N., Gunn, L. H., Felix, L. M., Car, J., & Majeed, A. (2014). Transtheoretical model stages of change for dietary and physical exercise modification in weight loss management for overweight and obese adults. Cochrane Database Syst Rev, 2(2), CD008066.
Romain, A. J., Bernard, P., Hokayem, M., Gernigon, C., & Avignon, A. (2016). Measuring the processes of change from the transtheoretical model for physical activity and exercise in overweight and obese adults. American Journal of Health Promotion, 30(4), 272-278.
Rutten, G. M., Meis, J. J., Hendriks, M. R., Hamers, F. J., Veenhof, C., & Kremers, S. P. (2014). The contribution of lifestyle coaching of overweight patients in primary care to more autonomous motivation for physical activity and healthy dietary behaviour: results of a longitudinal study. International Journal of Behavioral Nutrition and Physical Activity, 11(1), 86.
Simpson, S. A., McNamara, R., Shaw, C., Kelson, M., Moriarty, Y., Randell, E., ... & Espinasse, A. (2015). A feasibility randomised controlled trial of a motivational interviewing-based intervention for weight loss maintenance in adults. Health Technology Assessment, 19(50).
Wadden, T. A., Butryn, M. L., Hong, P. S., & Tsai, A. G. (2014). Behavioral treatment of obesity in patients encountered in primary care settings: a systematic review. Jama, 312(17), 1779-1791.
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