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RNs use behavior-change concepts to develop healthy habits

Monday December 31, 2012
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Karen Cotter, RN, MS, had many reasons to lose weight. In 2009, she was at her heaviest weight ever — 100 pounds more than when she graduated nursing school in 1994. She was on medications for hypertension and hyperlipidemia. When the now 42-year-old assistant professor of nursing at Oklahoma Baptist University College of Nursing in Shawnee talked to her students about taking care of themselves, she felt she was not a good role model.

But she also had many excuses for maintaining the status quo. At 6 feet 2 inches tall, she told herself she was just big, not overweight. She was too busy to exercise, ate on the run and frequently visited fast-food restaurants. Losing weight required “commitment to a regimen,” Cotter said, “and it was hard to find time.”

Cotter’s struggle to maintain good health is not unusual. According to several studies, more than half of nurses are obese, and more than one in 10 smoke. High stress levels and difficulty sleeping because of long, irregular workdays contribute to these poor health habits. Many nurses feel they are too busy to take care of themselves, said Suzy Harrington, RN, DNP, MCHES, director of the American Nurses Association’s Center for Health, Safety and Wellness. “We tend to help others before we help ourselves,” she said.

Change will do you good

If knowing about healthy lifestyles meant living them, nurses should be among the healthiest people on the planet. So why the disconnect between knowing what is healthy and actually doing it? What can nurses do to be successful in reaching their wellness goals?

They can start by looking to the behavior-change concepts they use with patients. “We teach [these concepts] to students, but we don’t apply those same models when we want nurses to change,” said Bernadette Melnyk, RN, PhD, CPNP/PMHNP, FNAP, FAAN, associate vice president for health promotion, university chief wellness officer and dean at the Ohio State University College of Nursing in Columbus.

Common models for behavior change include the Stages of Change and the Health Action Process Approach. “What’s important is to try a number of models that actually have good evidence behind them,” Melnyk said.

Inch by inch

The science of behavior change is still emerging, but those who study how and why people change say the process is long and complex. Nurses involved in wellness and behavior change said the first step toward a healthy lifestyle often is finding a strong motivation to change.

Cotter became motivated to lose weight about four years ago after a back injury. Surgery helped some, but the pain continued and her surgeon told her she either needed to lose 50 pounds or have a spinal fusion. At the same time, a friend suggested they start a walking routine and set a goal of just a mile or two around the neighborhood.

Taking small steps such as Cotter did and placing an emphasis on creating new habits is the best way for most people to make lasting change, behavioral experts said. “We need to ask ourselves what little things can we do,” Harrington said, such as drinking one less soda a day or parking a block from work and walking the rest of the way.

One of Melnyk’s personal wellness challenges was building breaks into her schedule. She used to work 12 hours without a break most days. But after becoming involved in the Nurse Athlete wellness program, which OSU is piloting, she realized she was not building in recovery time. She began with a small change — after every 50 minutes, no matter how important the task or meeting, she took 10 minutes to get up and walk around or stretch. As a result, she was reenergized and more productive when she went back to work.

Planning for change and possible barriers also is important, said Karen Gabel Speroni, RN, BSN, PhD, MHSA, director of nursing research at Inova Loudoun Hospital in Leesburg, Va., and co-creator of a research program called Nurses Living Fit. She suggests nurses start any self-care plan by documenting their lifestyle practices — what they eat, how much water they drink, how much sleep they get — and use that information to work in small changes.

Darlene Trandel, RN, PhD, FNP, PCC, an International Coach Federation-certified professional health coach and consultant for health, wellness, lifestyle and chronic care, has worked with many nurses to create environments to help them succeed. This may mean keeping sweets out of the house, planning an activity program or finding a satisfying substitute for a cigarette. She also helps them plan for things that might sabotage their good intentions, such as treats in the break room or feeling too tired to exercise after work.

Start small, finish big

After nearly a year of neighborhood walking, Cotter’s friend suggested they walk the 2011 Oklahoma City Memorial Marathon. Cotter said she thought she could do the 13.1 mile half-marathon, so they began to increase their walking times and distances, got up early nearly every day, trained with a running group and entered short races.
Although she wasn’t dieting, Cotter started decreasing portion sizes and increasing fruits and vegetables. She didn’t lose weight at first, but she dropped a dress size and began feeling better. People started telling her she looked better, too.

The half-marathon was a success, and the friends agreed they would try for the full marathon in 2012. They finished the 26.2 mile race in 6 hours, 46 minutes. By the start of the April 29 marathon, Cotter had lost 50 pounds and six dress sizes. She was off all but one medication, including the blood pressure medications she’d assumed she would take for the rest of her life. In January, three months before the marathon, Cotter made a resolution to give up fast food, a vow she has kept “with three small lapses,” she said.

Worth the effort

Creating and sustaining a healthy lifestyle is not easy, said nurses who work in behavior change, and the process almost always involves setbacks. Tracking progress, enlisting the support of others and changing strategies to avoid boredom can help people continue with healthy changes. “Don’t hate yourself for doing behaviors that are not what you wanted,” Speroni said. “Forgive yourself and move on.” Support from friends, family and colleagues through the entire change process is crucial, Melnyk said.

There are professional reasons for nurses to take care of themselves, said Speroni, whose report, “Effect of ‘Nurses Living Fit’ Exercise and Nutrition Intervention on Body Mass Index in Nurses,” cites a recent study that concludes patients may not have as much confidence in the wellness advice of nurses who do not appear to have followed it themselves. “Weight-appropriate nurses had more public confidence in their teaching,” her report states.

Nurses who strive for a healthier lifestyle can provide inspiration for their patients to change, Harrington said. They can acknowledge that change is difficult, but also show it can be done. “Health isn’t a goal, health is who we are,” she said. Making healthy changes provides “an opportunity to be excellent role models, educators and advocates.”

Cotter said her new motivation is to be a model for others. When she teaches her students about the need to take care of themselves now, she is passionate. She brings in photos from her marathons and uses her own experiences as an example. She still has some back pain and wants to lose 25 more pounds, but she feels like she can do it. The most important lesson of her wellness journey, she said, was “figuring out that you just make time. Taking the time is hard, but eventually the benefits are worth it.”

The Five Stages of Change

1. Precontemplation. Not thinking about changing. The person is in denial about an unhealthy habit or illness, doesn’t consider it serious or has tried many times to change and then given up. This is the stage when information and motivational interviewing may help someone find a reason to change.

2. Contemplation. Thinking about changing but not ready to act. The person is weighing the pros and cons of changing. At this stage, identifying barriers, concerns and support systems is important.

3. Preparation. Getting ready to make small changes. This is the time to develop realistic goals and timelines and to make adjustments to the environment that will support the change. Positive reinforcement is important.

4. Action. Taking definitive steps to change behavior. At this stage, positive reinforcement and having a specific goal in mind can help as the person makes the jump toward a healthier behavior.

5. Maintenance and Relapse Prevention. Striving to maintain the new behavior over time. Self-forgiveness and support from caregivers and others is important at this stage. Trying new strategies can help combat boredom. It’s also important not to take on too much and to forgive relapses under stress.

Source: University of Rhode Island Cancer Prevention Resource Center

Cathryn Domrose is a staff writer.Write to editor@nurse.com or post a comment below.
Tools for behavior change

At work

In the Nurses Living Fit program, which involved seven hospitals in Virginia, Maryland and South Carolina, nurses participated in a 12-week program that included exercise, yoga and nutrition sessions. The program was derived from Kids Living Fit, a hospital-based community program that educates children about healthy lifestyle choices for fitness and nutrition. Nurses received pedometers and tracked their steps, food and water intake and sleep. At the end of the program, nurses who participated in the program showed a greater reduction in body mass index and waist measurements than those who did not. Almost all participants recommended the program.

Though the healthy habits were not sustained 12 weeks after the intervention ended, researchers concluded the project offered a good workplace model to educate nurses about healthy changes for themselves and patients.

Researchers recommend offering the program year-round to help employees sustain lifestyle changes.
To read the research, see www.ncbi.nlm.nih.gov/pubmed/22441406

The Ohio State University School of Nursing is piloting a Nurse Athlete program, a two-day workshop to assess participants’ fitness and health and to help them achieve high levels of wellness, energy and performance. The program is based on one developed by the Human Performance Institute in Orlando, Fla., for corporate executives, and applies sports science to workers in high-stress fields. Participants include college faculty and staff and nurse leaders from the university medical center.

Workshops include physical fitness and nutrition components, including the need for breaks to exercise and eat healthy meals.

At the end, participants come up with one or two “energy management skills” to incorporate into their lives. Organizers are collecting data and, if the program is successful, hope to make it a national model of workplace wellness for nurses, other clinicians and university employees.

For more information, see www.nursing.osu.edu/news/news-headline-articles/sample-news-posting.html.

With a coach

Health coaches work with people to help them decide what sustainable changes they can make in areas such as nutrition, weight, physical activity, smoking, stress and life balance, and then assist them in making those changes. One-on-one coaching takes place in person or remotely.

Some health coaches also work as consultants, creating and setting up wellness programs for businesses. Although there is currently no official training or education requirement for coaches, an organization called the International Coach Federation is creating a national credentialing program in the United States, said Darlene Trandel, RN, PhD, FNP, PCC, an ICF-certified professional health coach and consultant for health, wellness, lifestyle and chronic care. Fees for individual coaching vary according to the training and experience of the coach, but typically cost about $50 per session, Trandel said. Many coaches offer discounted packages, such as three sessions a month for three months.

More information is available on Trandel’s website, “The Healthcare Coach” at www.thehealthcarecoach.com or through the International Coach Federation at www.coachfederation.org.

After 18 years of studying behavior, Stanford University researcher BJ Fogg, PhD, has concluded only three things will create change: an epiphany, changing context (what’s around a person) or taking baby steps.

Though he reckons he can’t create the first one for people, his program, “3 Tiny Habits,” offers free help with the others. His website invites participants to sign up online, learn about habits and select three small, concrete things they want to change (as an example, he offers his own decision to practice a chord on the ukulele every day after breakfast).

They agree to do those things for five days a week and respond to a daily email message he sends Monday through Friday.

For more information, see: www.tinyhabits.com.