FOLLOWING several years of rising death rates due to coronary heart disease (CHD), a decline in the death rate was observed from the 1960s until the 1990s. However, the rate of decline slowed in the 1990s. 1,2 While multiple factors have been invoked to explain these trends, it is important to consider the role of cardiovascular disease (CVD) prevention. Prevention counseling and lifestyle interventions targeting individuals at increased risk have been shown to reduce morbidity and mortality. 3 However, CVD risk factors did not decline at the same rate in the 1990s as in the previous decades. 4 Moreover, there are numerous reports that patients do not routinely have CVD risk factors assessed, or if assessed, that treatment is often inadequate to achieve treatment goals based on established national guidelines. 1 While the evidence for the efficacy of preventive therapies and lifestyle change continues to mount, a gap between what is recommended for CVD prevention and what is being observed in patients' risk profile remains.
While most health care providers acknowledge that prevention counseling is an important part of CVD management, many reasons have been cited for the lack of prevention counseling. Reasons frequently cited include lack of time for prevention counseling, 5,6 lack of infrastructure, 5 absence of system support, 7 lack of reimbursement for preventive services, 5,6 and a focus on patients with acute problems. 8 Other important reasons include skepticism that health promotion activities will result in behavior change, 5,6 absence of training, and lack of confidence in the skills to counsel patients about behavior change. 9,10 Nursing literature reports that nurses do not always deliver preventive education and counseling because of a lack of confidence in their skills and knowledge and the belief that they are ill prepared for this role. 11–13 Mullen and colleagues 14 studied reported self-confidence in health promotion counseling skills of a variety of health care providers. In this report, nurse midwives and PAs indicated greater confidence in their knowledge and skills in more topic areas. Generally, respondents reported the highest self-efficacy in counseling patients about blood pressure and smoking cessation and the lowest confidence in counseling about illicit drug use, isolation and loneliness, and emotional problems. When these same health care providers were asked to rate their certainty that patients would follow through on counseling and advice, the mean score was lower than their self-efficacy score for counseling. This literature illustrates the need to elucidate the skills and knowledge used in prevention counseling and the need to enhance nurse's confidence in providing such counseling in order to maximize the potential of CVD prevention. Thus, the purpose of this article is to outline the skill set and attributes of nurses and other health care providers who counsel patients to lower CVD risk factors and adopt lifestyle behaviors known to influence prevention. The behaviors that will be addressed include those related to dietary or eating habits, physical activity, smoking abstinence, weight control, medication-taking, and maintaining emotional health.
Before addressing specific skills, it is worth noting several positive trends that may enhance prevention outcomes. First, after incorporation of patient-centered counseling, patients adopt and adhere to risk-reducing behaviors related to nutrition, 7 smoking cessation, 15 and alcohol consumption. 16 Second, several studies have demonstrated the effectiveness of nurse case managers in delivering preventive care to individuals with documented CHD. 17–21 These studies provide evidence that with training in behavioral change theory and application, nurses are effective interventionists for CVD risk reduction. Third, between 1987 and 1997, the proportion of patients who saw nonphysician clinicians rose from 30.6% to 36.1% with an increased proportion of patients obtaining preventive services from nonphyisican clinicians. 22,23 Finally, there has been a paradigm shift in the role of nurses as it pertains to health promotion. 24 In the past, the nurses' role (and that of most other health care providers) has been described as authoritarian, prescriptive, persuasive, and providing generalized information and advice from the professional expert to “ignorant” lay person. 24 More recently the role emphasizes an empowering, client-centered, collaborative approach with a focus on individual beliefs and values, health and health-influencing behavior, enhancement of self-efficacy, and the acquisition of life skills. These trends support the role of nursing in health promotion and highlight the importance of identifying the skill set and provider attributes necessary for CVD prevention.
The following discussion addresses skills deemed essential by the members of the Council on Cardiovascular Nursing, Subcommittee on Prevention for one filling the role of counselor for health promotion and disease prevention. For ease in distinguishing roles, the health care provider (HCP) is referred to in the female gender, the patient in the masculine.
SKILL SET AND ATTRIBUTES OF HCPs
Expertise and knowledge
Expertise conveys an expert, one who possesses advanced knowledge, suggesting the HCP who functions in the role of health promotion counselor have extensive experience in risk factor counseling and/or advanced preparation. This may include nurses with advanced degrees, eg, clinical nurse specialists, nurse practitioners, or other specialty prepared nurses, eg, certified diabetes educators, or nurses trained in lipid management. Requisite basic knowledge includes knowledge of CVD risk factors and how to prevent, modify, or reduce risk. Studies show that patients want information about recommended lifestyles for risk reduction 25 and in general, see the provision of information from HCPs as a high priority in the health encounter. 25,26 With education and training, HCPs can improve their knowledge base; for example, their knowledge of cholesterol goals, and confidence in their ability to educate and counsel patients about risk-reducing behaviors related to achieving recommended serum cholesterol levels. 27,28 The HCP also needs to be skilled in interpreting research findings for one's own learning and to help patients interpret what they hear and read in the lay press. The HCP needs to be current in her knowledge of the empirical literature and apply the new information to preventive counseling. When patients wish to make regimen changes on the basis of the latest reports they have read or heard on the news, the HCP can help put the findings in perspective for the person. The knowledge required of the HCP in health promotion and preventive counseling is extensive and preferably acquired through experiential and didactic methods.
An expert is able to use simple, nontechnical language that patients can understand and also communicate effectively with a multidisciplinary health care team. The skill component entails being able to convey to individuals the necessary information in an appropriate format and at an appropriate time, that the format and timing of the information delivery is conducive to their receiving the intended message and then assist them to translate it into behavior change. Multiple communication approaches need to be considered when conveying important messages. For example, written material has a limited utility for information transfer and it is unknown if behavior change occurs. 29 Therefore, one should not rely solely on providing individuals with pamphlets but complement printed material with a discussion of the contents and determine if the person has read and understands the message. In an earlier published empirical review of clinical interventions, Haynes 30 reported that strategies to improve adherence to prevention or therapeutic regimens by changing knowledge alone had a 64% success rating. However, behavioral strategies had an 85% success rating, and combining educational and behavioral strategies resulted in an 88% rating. When therapeutic outcomes rather than adherence outcomes were reviewed, the success ratings for educational, behavioral, or combined approach resulted in 50%, 82%, and 75%, respectively. 30 Thus, the HCP needs to be versed in a variety of communication methods.
Recall of medical advice is affected by the communication process. The Medical Outcomes Study reported a varying rate of patients' recall of advice given by their physician, eg, less than 70% recalled advice to follow a low-fat or weight-loss diet or to exercise regularly. 31 This lack of recall was due to several reasons; however, communication between the provider and patient may have been a factor. When barriers to effective communication are present, the patient may have several reactions, eg, think they are wasting the HCP's time, feel uncomfortable to reveal information that may be unfavorable, omit information they think is unimportant, feel embarrassed not understanding the terminology being used, or think the physician has not listened and therefore does not have the information that is needed to make a good treatment decision. 32 In the patient-centered model, the patient's point of view is actively sought. 33 Using this approach, the HCP behaves in a manner that facilitates the patient openly expressing himself and asking questions.
The use of good principles of communication is likely to result in improved patient satisfaction and increased willingness to participate in the recommended preventive plan. Becker identified 10 principles of good communication based on studies of the general adult population, which possibly limits their generalizability to cultural subgroups, but does not detract from their general utility to guide HCP and patient interactions (see Table 1). 32,34 These guiding principles will ensure that the HCP is not only listening to the patient, but indeed, using active listening skills; that the HCP is asking for clarification of what was said, is paraphrasing, reflecting, and/or summarizing what she heard the patient say.
In developing a relationship with patients, one needs to reflect positive feelings through demeanor and behavior, promoting in the patient a sense of worth and security. A trusting relationship can be fostered by friendliness, confidence, and attentiveness. 35 It can also reflect the HCP's confidence in the individual's willingness and ability to make behavioral changes. Qualities of a therapeutic relationship 36,37 include
- empathetic understanding—demonstrating a sensitivity to others' feelings,
- genuineness—seen in an open and honest approach,
- unconditional positive regard—accepting others as individuals who are entitled to respect and care,
- intimacy and reciprocity,
- respect for the individuals' right to exercise control and choice, and
- mutual trust.
When patients are asked to disclose personal information, there is an expectation of acceptance and understanding. 38 Patients need to know that they are respected and taken seriously, even if they disagree with the HCP's perspective. 39 If patients know that they can trust the HCP, they are more likely to openly discuss their feelings and the problems and barriers they are facing in making lifestyle changes.
Assessment for behavior change
An essential skill is the ability to conduct a comprehensive assessment of the patient or client. The components of a comprehensive assessment include
- social and occupational background and current lifestyle,
- patient's perspective of his or her condition and the recommended treatment plan,
- patient's priorities and motivation for seeking treatment and changing behaviors,
- patient's readiness to make a change,
- previous attempts at modification of habits, past experience with counseling for risk reduction,
- best approach to jointly develop a therapeutic plan,
- feasibility of the patient being able to carry out the regimen,
- available resources.
Using the information obtained at the initial assessment, the HCP works with the patient to identify behaviors that need to be addressed and the individual's confidence or self-efficacy for changing that behavior. Targeted behaviors need to be negotiated with the individual and small, specific goals for incremental change identified by the patient. A plan for ongoing assessment and evaluation of progress needs to be jointly determined.
The reader may think that conducting this type of assessment may require far more time than is allotted in the typical clinical encounter; however, some of this information can be acquired by having patients complete an assessment form while waiting for their appointment. Some questions may be better posed directly to the patient. When time is limited and there is one risk factor to target, it is better to ask a few questions (eg, what is the patient's priority for behavior change, is the person ready to make some changes, what are the major obstacles to behavior change, confidence rating of his ability to follow through) and counsel the patient with this information than to permit the opportunity to pass without intervening.
Skills in using behavioral strategies
Principles of learning and behavior change theories (eg, social cognitive learning theory, readiness for change or self-efficacy) 40–42 provide the foundation for strategies to change behavior or to improve motivation. When targeting behavioral change, one of the first steps is increasing the patient's awareness of their behavior, eg, what, how much, and how often they eat, exercise, smoke, feel upset or stressed, or take their prescribed medicines. Self-monitoring is the key strategy to increasing one's awareness of behavior. This does not require an elaborate diary or notebook but merely asking the patient to record for a specified period everything about the behavior targeted for modification. While the self-monitoring may actually change the targeted behavior, its use for increasing awareness is of prime importance. 43 The HCP must review the recorded behaviors with the patient. This provides an opportunity to have the patient identify the problem areas, how they might be addressed, what are the specific behaviors that the patient thinks are important to change, and how he would like to change them. From this encounter, goals can be established for targeting those behaviors.
Goal setting theory predicts that under most circumstances setting specific goals leads to higher performance compared to no goals or vague ones. 44 Goals may vary by degree of difficulty, specificity, and complexity. For example, goals that require a large number of intended outcomes, such as making dietary changes, are more complex than those that require fewer intended outcomes, eg, medication-taking. Merely setting a goal does not automatically instill motivation to achieve the goal. However, if the patient is committed and interested, goal setting can motivate a person more than absence of goals or vague advice such as “you need to lose weight,” “be more active,” or “do the best you can.” Breaking a long-term goal down into more specific shorter-term goals may be helpful and provide increased opportunity for feedback. Success with short-term goals also enhances self-efficacy and performance satisfaction. 45 For example, rather than setting a general goal of reducing one's fat intake by a certain percentage, it is better to set a proximal goal such as substituting high-fiber cereals for high-fat breakfast foods. Breaking the long-term goals down should be a collaborative exercise for HCP and the patient. The selected goal should be realistic and within a high range of the person's level of self-efficacy (eg, on a scale of 0 to 100, how confident the person is that he can do the activity to achieve the goal). It is recommended that goals focus on behavior change, eg, eliminating a food item, rather than on physiological outcomes, eg, low-density lipoprotein cholesterol. Behaviors are more directly under a patient's control, while physiological changes can be influenced by several factors. 44 Goals considered too difficult will not be attempted and goals too easy will not be taken seriously or provide a sense of satisfaction once achieved. Once the goal is set, regular feedback on goal attainment is important to instill a sense of learning and mastery. 44 The use of visual charts demonstrating progress is a good method for feedback.
Social support is a positive influence by significant others or friends on an individual's behavior in following the recommended preventive plan. A spouse who assists in providing the recommended meal plan, or the person who acts as a “buddy” in an exercise program can provide needed support. Wing and Jeffery 46 demonstrated the strength of social support in their weight loss study; compared to individuals who came alone into a weight loss program, those who brought 3 friends or relatives along had a better completion rate (95% vs 76%) and a higher proportion maintained their weight loss in full for 4 to 10 months (66% vs 24%). 46 Another source of support can be the presence of role models in the individual's environment; an individual to whom the patient can relate who is modeling good health behaviors. The stress-buffering channel is another source of social support, where individuals in the network absorb some of the stress for the individual. 47 The HCP needs to query the patient about support persons who are available and, if necessary, help the patient enlist support. When indicated, it can be very useful to involve support persons in the counseling, if the patient wishes.
Motivational interviewing is a patient-centered counseling approach for assisting patients to examine and resolve ambivalent feelings about behavior change. 48 HCPs can obtain specialized training in this counseling technique through workshops and professional meetings. Those not specially trained in the technique can employ what has been called “brief motivational interviewing,” developed for use in opportunistic health promotion encounters when time is limited (ie, 30–40 minutes). This approach 49 includes 4 clinical tasks:
- setting an agenda,
- quick assessment of motivation and confidence,
- making decisions and setting targets,
- exchanging information.
These are negotiation strategies but preserve the principle that motivation to change behavior should come from the patient, not be imposed by the HCP.
Readiness to change is based on Prochaska's Transtheoretical Model, which is an integrative framework for understanding how individuals move toward adopting and maintaining health behavior change. 41 The 6 stages of change (precomtemplation, contemplation, preparation, action, maintenance, and termination) suggest that there is a temporal dimension to behavior change, it just does not happen as an event. Individuals can move back and forth across the stages. The theory has received empirical support across behavioral domains, in particular in exercise-related and smoking-related behaviors. 50 The clinical relevance of this theory for health promotion counseling is determining the patient's stage regarding making behavior change prior to discussing the change. This can be determined with a simple question such as “based on a scale of 0 to 10, 0 being not ready at all, how motivated are you at this time to do.…? This information can be used by the HCP to guide the discussion and action plan for risk reduction.
Problem solving51 is a strategy that entails 4 steps:
- identify the problem that is preventing the person from meeting the goal
- have the individual generate solutions to the problem
- select one solution to test
- evaluate the success or failure of that solution in resolving the problem
If the solution is unsuccessful, the person needs to test the second proposed solution, and so forth. This is particularly useful when the patient has encountered barriers. If the person has been successful but anticipates a high-risk situation that may threaten his success, eg, upcoming vacation travel, anticipatory problem-solving can be undertaken prior to the anticipated situation. This strategy can also be used as part of relapse prevention, preparing the patient for situations that may result in lapses. Lapses, considered slips that last a couple of days, are common occurrences. Planning for lapses can prevent them from becoming a relapse.
Skill in considering the patient's attitudes, beliefs, and environment
Patient's attitudes and beliefs about the cause of their disease and their beliefs about the treatment may influence their willingness to engage in or adhere to preventive care. 52 If a patient believes that hypertension is caused by stress, they are likely to be less compliant with exercise or dietary interventions and medications such as diuretics. A nonjudgmental discussion of beliefs may be required prior to holding any discussion of the benefits of current preventive therapies. It is suggested that health beliefs need to be examined in the context of the specific health behavior and for the specific population and setting. 53 Beliefs are influenced by culture or religion. The ability of health beliefs to predict behavior is related to whether or not the person has experienced the behavior and adjusted his beliefs accordingly. 53
Beliefs are considered in several of the theories used to explain behavior change. Treatment efficacy is a component of Bandura's outcome expectancy, 54 one's belief or confidence that if they perform the recommended behavior, it will lead to the desired outcome. The Health Belief Model considers ones' belief in the efficacy of an action to reduce the perceived health threat. 55 However, for the behavior to occur, the potential barriers, such as costs, risks, and complexity of the regimen, must not outweigh the perceived benefits. Azjen and Fisbein's Theory of Reasoned Action 56 includes the beliefs of important others and their influence on the patient. The concept of “reasoned decision making” is pertinent to patients' decision-making about preventive therapies. The greater the demand for behavioral change the less likely the person will be able to sustain the behavior for the long-term. 57 Also, unpleasant or potentially unknown effects can be a deterrent to the adoption or maintenance of a recommended regimen, eg, medication side effects. 58 A familiarity with the behavior change theories and their major constructs enables the HCP to assess how beliefs may influence an individual's willingness to engage in preventive behaviors.
Environmental factors play a large role in behavior change. These factors need to be assessed and addressed particularly in interventions targeting changes in eating or smoking behavior. The environment bombards an individual with cues for unhealthy eating, and provides little incentive for being physically active. For cigarette smokers, environments or individuals may provide negative feedback and/or reinforcement for the risk behavior. Stimulus control, a behavioral therapy strategy, addresses these cues or messages by teaching individuals to change the environment to eliminate the cues for undesirable behaviors and include positive cues for appropriate eating and exercise behaviors, or for smoking cessation. 59
Attributes of the HCP
Limited work has been done on health care professionals' reported confidence or self-efficacy related to performing health promotion activities. Actual practice and encouragement from practitioners influenced self-efficacy for health promotion counseling of medical students. 10,60 Laschinger and colleagues 10 studied nursing and medical students to determine if clinical rotations in family nursing and medicine would affect their confidence in their knowledge and ability to counsel patients in health promotion. Self-efficacy levels were similar prior to the experience but immediately postexperience and 3 months later, nursing students' self-efficacy was significantly higher than that of the medical students. Programs that provide educational seminars with opportunities to role-play and practice counseling skills resulted in nurses reporting increased ratings of self-confidence in their knowledge and ability to counsel. 27 An enthusiastic, confident HCP likely helps to motivate patients undertaking behavior change.
Flexibility suggests an ability to determine realistic means to achieve goals. The HCP needs to be open to what the priorities of the patient are and to assist the patient to readjust goals if circumstances change. It also means accepting that the patient may not be ready to make any changes and therefore, supporting the patient in developing a readiness to consider behavior alterations. It may be most appropriate to inform the patient that prevention strategies will be considered at the next encounter.
Because CVD risk reduction encompasses an array of behaviors, it is often beneficial to collaborate with members of other disciplines in planning and implementing preventive care, eg, a nutritionist, exercise physiologist, or psychologist. The HCP sets a good example by being an advocate for health promotion and serving as a role model to patients and colleagues by utilizing health promotion strategies in her own lifestyle habits.
Interview and group process skills
Being knowledgeable in the conduct of a good clinical interview as well as how to facilitate the group process are valuable skills for a HCP in health promotion. Following the principles of communication outlined by Becker 32 will enhance a person's interviewing skills (refer to Table 1).
Technology and resource utilization skill
Information technology has revolutionized a good part of health care but on an individual level, most HCPs rely on standard forms of communication, such as face-to-face, telephone, mail, and fax. More recently, providers are beginning to use electronic-mail and the Internet. 61 Technology also has contributed databases that can be used to track patients and their progress, and devices that can assist the patient and the HCP to monitor the patient's behavior, providing data to tailor counseling to an individual's specific situation. Electronic monitors objectively monitor a variety of behaviors including medication-taking, physical activity and energy expenditure, self-reported food intake, and smoking cessation. These devices monitor a patients' behavior in the context of their daily activities and these data can be downloaded to a personal computer for the HCP's review. 62,63 Unlike written diaries, the patient cannot edit what was previously written or entered in his self-monitoring diary, which may improve the accuracy of the record. 64 Clinical application of such monitors has been limited; however, Burnier and Brunner 65 demonstrated their value as an adjunctive clinical intervention when treating a patient with hypertension. Being able to show the patient the pattern of his medication-taking habits was an effective strategy to improve compliance to preventive therapy.
Less expensive devices are available to the lay public to purchase, eg, personal digital assistants (PDAs). Software is available for individuals to monitor their food, calorie, fat, and salt intake, as well as the calories expended in physical activity and exercise. (Balance Log™ by HealtheTech, Bolder, CO). If the HCP is knowledgeable in the use of these devices and has compatible software, the patient may download the data from the PDA and provide it to the clinician for review. Beyond self-monitoring, some devices provide instant feedback, for example, charts and graphs on energy intake and expenditure, and may provide a source of motivation for patients attempting changes in these habits.
Four types of mediating structures offer great potential as collaborators in health promotion: mutual help groups, the Internet community, community coalitions, and religious organizations. 66 Religiosity is a robust factor in maintenance of health. Moreover, religious organizations often provide their own outreach efforts for health-related activities. 67 This makes them an ideal partner in health promotion efforts, especially in addressing the gaps in health status for racial and ethnic groups.
Community and volunteer organizations whose purpose is health promotion and disease prevention are also valuable resources (eg, the American Heart Association [AHA], the National Heart, Lung, and Blood Institute [NHLBI], and the American Lung Association [ALA]. These organizations have printed materials available and offer extensive materials to both the lay public and health professionals through their Web sites. 68 The AHA and ALA sponsor community-based classes and workshops that promote healthy lifestyles; the AHA and NHLBI have developed algorithms for primary and secondary prevention of CHD.
Besides governmental and nongovernmental organizations, professional organizations can work collaboratively in providing training for their members in health promotion counseling skills. The greatest potential for making a substantial impact on the population's cardiovascular risk is through collaboration with community and professional sources. Addressing primordial, and to a certain extent primary prevention, requires access to individuals prior to their entrance into the health care system, which requires community intervention. Addressing secondary prevention calls for a combined effort of multidisciplinary health care professionals, representatives of community agencies, and the lay public.
Nurse case-managed systems for CVD risk reduction have proved efficacious in several research settings and some dissemination into clinical practice models has occurred. Some common barriers to CVD prevention include the lack of skill and motivation on the part of HCPs as well as lack of interest or motivation on the part of the patient. These barriers may be reduced through training in communication and counseling skills. Prevention counseling is a complex process, incorporating several theoretical perspectives, techniques, and behaviors. Prevention counseling requires training, practice, and time. Acquisition of the skills described in this article will assist HCP deliver effective preventive care and has the potential to impact morbidity and mortality associated with CVD.
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