As health care professionals we often struggle with the issue of patient compliance. Whether we are trying to instill the concept of carbohydrate choices or achieving regular exercise, it is often difficult for us to motivate our patients to practice what we may be preaching. Perhaps one of the most meaningful concepts that we try to present to our patients is the importance of regular exercise.
Yes, regular exercise defined by most as 30 minutes of rhythmic/aerobic activity everyday. What is it that determines whether a patient will comply with the exercise curriculum discussed in diabetes education? I believe the key element is motivation. We have to be motivated to alter or change our current lifestyle habits. Unfortunately, being diagnosed with a disease may not be enough or a motivating consequence for most patient. The patient may not perceive “pre-diabetes” to be serious enough at the particular moment to warrant dietary changes or exercise intervention. Perhaps the patient does not believe he/she has much control of their future and, consequently, they figure they are doomed and have little hope. What I would like to focus on in this article are the aspects of motivation that we as diabetes educators can influence: (a) assessing a patient’s readiness to change, (b) the decisional balance, and (c) goal setting.
Readiness to Change
Understanding where our patient exists in their willingness to adopt healthier behaviors is the first step in being able to effectively motivate our patients. It does not help us to start incorporating plans, goals, and strategies for a patient that does not believe that a change is warranted. The Stages of Change is a conceptual model developed by Prochaska and DiClemente (1982) to help illustrate the cyclical process one experiences when engaging in a behavior change. Below are descriptions of each stage and the implications of each stage for a diabetic patient in need of healthier exercise behaviors:
Precontemplation : During this stage the patient is considering change, is aware of only a few (if any) negative consequences of current behavior and is unlikely to take action soon. Patient responsibilities are to think about how their daily and/or life problems are linked to consequences resulting from a poor diet and/or inadequate exercise habits.
Contemplation: Patient is aware of some pros and cons, but feels ambivalent about change and has not yet decided to commit to change. Patient responsibilities are to think about the reality of the “pros” of his/her diet and exercise habits (e.g. tasty food, convenient exercise) and how those “pros” may agree or disagree with what he/she really wants from life.
Preparation: This stage begins once the patient has decided to change and begins to plan steps toward a healthier lifestyle. Patient responsibilities are to make personal commitments to themselves. Goal setting with a solid plan is essential in this stage.
Action: Patient tries consuming a healthier diet and engages in some exercise, but these behaviors are not yet stable. Patient needs to work on skills and goals that will help him/her maintain a healthy diet and regular exercise habits. Surrounding themselves with a supportive social network is crucial.
Maintenance: Patient establishes a new healthy diet and a regular exercise regimen on a long-term basis. Relapse prevention is the main concern for the patient.
Is your patient in the pre-contemplation stage or action stage? Deciphering the current stage your patient is in can help you provide them with the appropriate tools to help them move to the next stage of change.
So how does the patient get and stay motivated to achieve the goals they set? Motivation is based on a decisional balance. The decisional balance considers the pros and cons of the patients current exercise habits. What are perceived “pros” for the current exercisers? For example, a busy individual who fits two days of aerobic exercise into his or her weekly schedule perceives this behavior to be a “pro” because despite the busy schedule, they are still getting exercise. What this individual needs from a diabetes educator at this point is to be gently guided to discover how this pro actually contradicts the ultimate exercise goal. Specifically, although the patient is exercising, which does indeed warrant our support and praise, he/she is not exercising to the extent that will realistically help them control their blood sugar levels. So what can be done to help our patients become more aware of the benefits and consequences of their current exercise behaviors? Writing down the pros and cons on a piece of paper can be enlightening. It can create an awareness of the contradictions between the patients’ current behaviors and the behaviors we are asking them to embrace. The purpose of this type of activity is not to throw their personal values and/or behavior back at them in an adversarial manner; rather we are simply trying to get our patients to motivate themselves by exploring discrepancies in goals they have set for themselves. These are not our goals, but they are the goals that have been created by our patients. We need to remind our patients of this fact to enhance their awareness of their ability to control their own healthy lifestyles.
Once our patients have made the decision to learn about and adopt healthier exercise habits, how can we help our patients generate and maintain motivation? Goal setting is not only an essential aspect of motivation, it is an effective intervention that has garnered significant empirical support. The goals that a patient sets should reflect his or her personal health needs specific to diabetes self-management. Goals should be attainable, specific, measurable and flexible. The long-term goal can be, for example, to help control blood sugar levels by engaging in 30 minutes of aerobic/rhythmic activities 5-7 days per week. Short-term goals are the stepping stones to achieving this long-term goal. For example, the patient who has never participated in regular exercise may choose to set a short-term goal of exercising 20 minutes three days per week for three weeks. This goal is attainable because it is realistic, specific in that it states a deadline for assessment (three weeks); measurable in that it gives times and days; and flexible in that the patient can change the time and days of activity if he/she feels they are not doing enough or doing too much. Empowering the patient to adjust the goal is essential; it communicates to them that they are in control of their health decisions.
Kristina Sandstedt, MS received her Masters of Science degree from the University of Montana-Missoula. She is certified as an Exercise Specialist through the American College of Sports Medicine. She is currently working as a Clinical Exercise Physiologist and Diabetes Educator for the Early Outpatient Phase II Cardiovascular Rehabilitation unit and the outpatient Diabetes Self-Management classes as well as individual consultations at Boone Hospital Center in Columbia, Missouri.
Kristina recently co-presented “Diabetes-What You Need to Know” at the National Speaking of Women’s Health Conference.