Page 415 - Encyclopedia of Nursing Research

382 n PATIeNT CONTRACTING

setting. For example, patients may request setting out athletic shoes at night may cue
more convenient appointments, magazines, walking the next morning.
P lottery tickets, etc. Tokens or points can be Behavioral analysis can identify the
collected and exchanged for a larger rein- multiple small steps that comprise the adher-
forcer (Boehm, 1992). ence behavior. When the small steps are
Behavioral analysis is the foundation identified, the behavioral strategy is to per-
of the patient contracting intervention. form a small step of the adherence behavior
Behavioral analysis is the process by which for a designated period of time. When that
the patient’s behavior is observed, recorded, small step is being successfully performed,
and analyzed to describe the successive the patient moves onto the next small step.
approximations of the adherence behav- eventually, patients gradually achieve per-
ior, the antecedent events that precede the formance of the adherence behavior (Steckel,
behavior, and the consequences that follow 1982). This behavioral strategy is effective
the behavior. The behavioral data used in the because patients are often overwhelmed by
analysis are obtained by the patient through expectations of a treatment regimen, which
self-monitoring (Boehm, 1992). can lead to nonadherence. For example, sed-
Behavioral analysis begins with the entary patients who are beginning a walking
patient self-monitoring the adherence behav- program might start by walking 5 minutes
ior. Increasing self-monitoring is done using five times per week. each week the walking
Smartphones or Internet Web sites. Self- goal is gradually increased until they achieve
monitoring provides baseline data that can their goal of accumulating 30 minutes of
be used to determine the effectiveness of the moderate intensity walking 5 days per week.
behavioral strategies implemented later in Positive reinforcement is the behavioral
the behavior change process. By using the strategy in which a positive consequence is
patient’s self-monitoring records, the nurse provided contingent upon performance of
can teach the patient to identify anteced- the desired behavior, which results in an
ent events that precede the behavior, small increase in performance of the behavior.
steps that comprise the behavior, and con- Behavioral analysis can identify positive
sequences that follow the behavior. On the consequences for behaviors and provide
basis of the behavioral analysis, behavioral ideas for new consequences (Boehm, 1992).
strategies are specified that will assist in the The behavioral strategy is to arrange posi-
behavior change. tive reinforcement to acquire or maintain a
An antecedent event precedes a behav- desired behavior. For example, adopting a
ior and prompts the behavior by identifying walking program will be strengthened if a
conditions under which a behavior will be positive consequence follows each walking
reinforced or not (Boehm, 1992). Much behav- goal that is met. Positive consequences can
ior is under the control of antecedent events. be pleasurable items and activities; social
When behavioral analysis demonstrates that reinforcement, such as praise; and cogni-
the behavior the patient chooses to decrease tive reinforcement, such as feelings of pride.
or eliminate is cued by an antecedent event, Conversely, eliminating positive reinforce-
the behavioral strategy is to rearrange, to ment can be used to decrease or extinguish
avoid, or to eliminate the antecedent event. an undesired behavior. For example, eating
For example, the patient may take a different with selected companions may eliminate
route home to avoid stopping at a fast food positive consequences for inappropriate food
restaurant after work. Conversely, when the item selections.
patient chooses to increase a behavior, the There are several directions for future
behavioral strategy is to arrange an anteced- research. First, the feasibility and cost-
ent event to cue the behavior. For example, effectiveness of changing single versus