Page 921 - Cardiac Nursing

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C HAPTER 4 0 / Adherence to Cardiovascular Treatment Regimens 897
for behavioral analysis (i.e., the patient and provider can identify behaviors and population groups, including weight loss, 136,137
problem behaviors that could be altered or high-risk situations adherence to treatment and follow-up, 137 increasing physical ac-
that can be anticipated and modified). The provider reviews the tivity, 138 improving medication adherence among hypertensive
self-monitoring record and provides reinforcement for progress blacks, 139 and smoking cessation. 140 A meta-analysis of 72 trials
and/or maintenance. An alternative to the paper-and-pencil diary showed a significant effect of motivational interviewing on out-
exists today in the form of a PDA; dietary and physical activity comes such as blood cholesterol, blood pressure, and weight loss in
software programs are available for use on PDAs, which facilitate 74% of the studies. 135 One needs to obtain training in the appli-
easier access to information on nutrient composition of foods and cation of this strategy, which is available at professional meetings
permits identifying the type and duration of exercise performed. 70 and academic centers.
This format has also been pilot tested for use in medication ad-
herence 132 and in recording eating and exercise behaviors. 104 Stimulus Control
There is increasing evidence that self-monitoring is related to bet-
ter outcomes in behavioral intervention studies. 133,134 An imme- Using information recorded in the diary on the circumstances of
diate benefit of self-monitoring is that the patient develops an the behavior allows identification of the antecedent or trigger for
acute awareness of his/her current behavior and how this may be problem behaviors. The patient is counseled to remove the stimuli
inconsistent with one’s health-related goals. Kanfer has described and to restructure the environment to minimize the will power
self-regulation as a process having three distinct stages: self-moni- needed to overcome strong stimuli, for example, remove unhealthy
toring, self-evaluation, and self-reinforcement, and suggests that foods from view and have healthy foods visible and readily avail-
changing habits requires developed self-regulatory skills. 130,131 able, have exercise equipment in a place that is easy to access, have
The behavioral strategy of self-monitoring is central to this morning medications near the coffee maker.
process, and includes deliberate attention to some aspect of an in-
dividual’s behavior and recording details of that behavior.
Modeling Behavior
Reinforcement The patient can observe a credible model perform a task or have an
activity demonstrated, which may be done by watching a video or
Giving positive feedback to the patient on progress made, sup- live action. It is important that the patient find the model credible
porting self-motivation by highlighting accomplishments, en- and the activity feasible, such as observing fellow patients exercis-
couraging continued progress, and instilling confidence in the ing in cardiac rehabilitation programs, or a cooking or exercise
person’s capability of meeting a goal all constitute reinforcement. demonstration.
When providing positive feedback, focus on the behavior that the
person has achieved rather than on the clinical outcome. Having Social Support
a diary to review provides a mechanism to relay support. The self-
reinforcement component comes from the provider in assisting Social support includes enlisting others to assist the patient
the patient to attribute the progress to his/her own efforts rather through the behavior change process, and inclusion of supportive
than to the provider. others from various aspects of the patient’s life (e.g., family,
friends, coworker, community). The purpose of this strategy is to
Self-Efficacy Enhancement have supportive allies in place during successes and failures. This
may take the form of enlisting a “buddy” for exercise or eating be-
Self-efficacy enhancement strategies are based on the sources of self- havior change, or having someone there for reinforcement. Social
efficacy and include providing opportunities for successful per- support has been shown to be important in behavior change, but
formance or mastery, which can be achieved through realistic goal particularly in programs of dietary and physical activity change;
setting. Provide feedback and praise for progress (achieving specific also the presence of a supportive other can be instrumental in im-
goals) can be done though review of self-monitoring materials; con- proving medication adherence.
vince the person that he or she is capable of performing the activity
through verbal persuasion, and interpret symptoms of physiologic Ongoing Contact
response, such as breathlessness due to inactivity and diminished
symptoms after a program of regular exercise. Several of the above- Continued contact through mail, telephone, or the Internet has
described strategies are very effective in increasing self-efficacy. consistently demonstrated improved adherence in maintaining
behavior change. The mail can be used as a method of ongoing
Motivational Interviewing contact by having patient’s return weekly diaries of eating, exer-
cise, or medication-taking behaviors, which could be followed by
This is a directive, client-centered counseling style for helping pa- a brief phone call to provide feedback. This technique adds the ac-
tients examine and resolve ambivalence about behavior change. In countability factor and encourages ongoing communication with
settings where time and possibly clinician expertise is limited, an the provider. Similarly, the telephone provides ongoing support
abbreviated version of the technique can be applied. Motivational and assistance with problem solving. A brief phone call to the pa-
interviewing has four core principles: express empathy, develop a tient can provide encouragement that may help the patient sustain
discrepancy, roll with resistance and support self-efficacy. It is the behavior during a challenging period. Regular telephone con-
through the technique of reflecting listening that the interviewer tacts need to have a structure in terms of purpose, what is to be
helps individuals identify and resolve uncertainty, thereby increas- accomplished, approximate time allowed, and a schedule of when
ing intrinsic motivation to change. 135 Motivational interviewing the calls should occur. Scripting or outlining the main steps to fol-
has been shown to be effective across a wide range of health-related low in the contact can help maintain a focus and ensure that each