Page 922 - Cardiac Nursing

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898 PA R T V / Health Promotion and Disease Prevention
point is addressed. Because of the increasingly busy lives of pa- Relapse Prevention
tients, it may be more difficult to have regular phone contacts; 143
however, more people are using the Internet (e.g., discussion Based on the work of Marlatt and Gordon, the relapse prevention
board or e-mails) as a means of ongoing contact. 108 When con- technique emphasizes that slips or lapses are natural occurrences in
sidering initiating a telephone or telemedicine follow-up system, the process of behavior change. Patients are taught to anticipate
the provider needs to consider the purpose or goal of the system, high-risk situations and to identify ways to cope with the situation.
if these can be met given the frequency and duration of the When possible, patients should practice problem solving to develop
planned contacts, and the costs in terms of staff time. One study these skills better and rehearse the strategies they would use to resolve
reported a large effect size following the use of telephone calls and the threat to adherence or maintenance. Patients need to be re-
provider feedback for improving adherence to lipid-lowering minded lapses will occur and not to be discouraged or give up the
medication therapy. 141 entire behavior change program because of one slip.
Cueing Tailoring the Regimen
Cueing consists of setting up a system of reminders or cues to per- Tailoring the regimen addresses the patient’s capability to carry out
form certain activities (e.g., a sticker to remind the person to take the plan, that is, what is realistic for the patient to achieve in be-
a medication, or setting out exercise shoes as a prompt to exercise havior change. It includes accommodating the patient’s schedule
on a busy day). This strategy is used frequently to improve med- for appointments, being sensitive to cultural issues in recommend-
ication adherence. ing dietary change or other behaviors, and being sensitive to liter-
acy as well as to financial constraints in general. It is an important
consideration in medication-taking compliance (e.g., considering
Habit Building the costs, memory requirements, and schedule when prescribing a
Habit building is derived from the stimulus control model and is drug that may be available in numerous dosing forms).
based on the premise that a large amount of behavior is automatic
and responsive to stimuli. It further suggests that behavior can be Use of Frequent, Short Bouts,
modified by establishing a relationship between the behavior stim- Home-based, or Moderate-Intensity
ulus and the target behavior, such as pairing a new behavior (med- Exercise Sessions
ication taking) with an established behavior (brushing teeth). Using
cues, as described previously, is a related strategy. These techniques There is ample evidence of using frequent, short bouts to induce
may be particularly helpful when in an unusual environment (e.g., exercise benefits. Accumulated exercise using short bouts (2 15
traveling). Pairing the medication bottle with the toothpaste or min, 3 10 min) has similar benefits in aerobic fitness and weight
adding a note to the travel alarm clock may prevent an episode of loss with that of one 30-min bout of exercise. The effectiveness of
nonadherence. this approach to improving VO 2max was demonstrated among
healthy sedentary adults in Hong Kong 144 and Canada. 145 In a re-
Contracting cent paper published by the American College of Sports Medicine
and American Heart Association, 146 the duration of short bouts
A form of public commitment, contracting involves the patient in was more clearly defined. Exercise short bouts, lasting 10 or more
the development of the plan and clearly specifies in writing what is minutes, are recommended to meet the minimum 30 minutes of
expected, the time frame, and any conditions for a reward if the moderate intensity physical activity level on five days per week. In-
goal is achieved. The contract needs to specify a behavior rather dividuals can be reassured that they can be flexible in planning
than the health outcome, and should specify the incremental steps their exercise routine by using the short-bout approach. Patients
necessary to achieve a goal that is attainable and valued by the pa- often do better in terms of long-term adherence and fewer injuries
tient. A contingency reward may be included for achievement of if they are instructed to follow a moderate-intensity exercise pro-
the goal. This needs to be a reward valued by the person and rein- gram.
forcing to the healthier behavior, such as a new outfit or fun activ-
ity for someone in a weight reduction program, but not food or a Use of External Cognitive Aids
dinner at their favorite restaurant.
External cognitive aids include appointment reminder letters, fol-
Problem Solving low-up letters for missed appointments, reminder cards for medica-
tion refill, medication calendars or reminder charts, and unit-of-use
Problem solving involves several steps, beginning with identification packaging of pills. Any of these strategies can enhance adherence
or acknowledgment of a problem, defining the problem, generating to appointment keeping and to medication taking. Appointment
potential solutions, selecting one solution or set of actions to resolve reminder calls and letters are used effectively in most long-term
the problem, and then evaluating the success of the attempt to re- clinical trials.
solve the problem. 142 This technique is integral to maintenance of
behavior change and is facilitated by reviewing self-monitoring Nurse Case-Managed Care
records and identifying high-risk situations. Anticipatory problem
solving can help a patient prepare for an upcoming situation, such as Serving as case managers, nurses provide clinic and telephone fol-
a major social event or vacation. It is ideal if the provider can have low-up, initiate therapy for risk reduction, and provide counseling
the patient role play the interactions that might occur in a social sit- for behavior change (e.g., smoking cessation, dietary change).
uation and how the person would use the new strategy. Use of this treatment model has demonstrated improved clinical