Home Health Care Nursing Application of the Transtheoretical Model of Change to Patients with Congestive Heart Failure: A Case Study - PDF

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Home Health Care Nursing Application of the Transtheoretical Model of Change to Patients with Congestive Heart Failure: A Case Study WYONA M. FREYSTEINSON, PHD, MN H O N O R S O C I E T Y O F N U R S I
Home Health Care Nursing Application of the Transtheoretical Model of Change to Patients with Congestive Heart Failure: A Case Study WYONA M. FREYSTEINSON, PHD, MN H O N O R S O C I E T Y O F N U R S I N G S I G M A T H E T A T A U I N T E R N A T I O N A L 2 3 R D I N T E R N A T I O N A L N U R S I N G R E S E A R C H C O N G R E S S B R I S B A N E, A U S T R A L I A 3 0 J U L Y - 3 A U G U S T Objectives Explore the six stages, three key concepts and stage appropriate interventions of the Transtheoretical Model of Change (TTM). Reflect on a case study where TTM was used to help an older gentleman with congestive heart failure (CHF) change his poor health behaviors. The Problem WHO: cardiovascular disease causes greatest number of deaths CHF patients: frequent emergency rooms visits and hospitalizations Home care: limited ability to deal with complex heart failure symptoms One Solution A specialized team of clinicians to care for patients with stage 3 and 4 CHF: Cardiac Life Team members: physicians, nurse practitioners registered nurses and therapists Cardiac Life Complex & Chronic Home Care Clinical Delivery Model For Congestive Heart Failure o Enhance health promotion (TTM) o Effectively palliate symptoms o Improve safety o Decrease caregiver burden o Improve well-being o Decrease emergency room visits o Decrease hospital readmissions Complex needs Special needs Whole Population Keys to Success Nurse Practitioner (NP) home visits Weekly clinical CHF team meetings Physical therapists trained in TAI CHI Palliative care Transtheoretical Model (TTM) of Change Why TTM? TTM has been effective in many areas including: Smoking cessation Weight reduction Exercise Healthy eating Why TTM? TTM is a model that emphasizes change takes time. Transtheoretical Model (TTM) Three core concepts Six stages or time points Ten process steps Prochaska, Johnson & Lee, 2009 Core Concept: Decisional Balance Decisional Balance: potential pros and cons I decide: If I want to think about changing. Based on why or why not I think I should change. If I should keep this new healthier habit. If I should return to the old habit. Core Concept: Self-efficacy Self-efficacy: confidence one has in one s self One may say, I: Can change! Can t do that. Am not able to change. Core Concept: Temptation Temptation: how much one can resist returning to old behaviors One may think, I: Miss my habit. Hate thinking about this (new health behavior) all the time. Do not see what this (new health behavior) is doing for me. TTM Stage: Precontemplation Precontemplation stage: No thought or consideration of change May not know now what the unhealthy behavior is May choose to do nothing about it Nursing Actions: Assess patient s understanding of healthy behaviors Provide health care education TTM Stage: Contemplation Contemplation stage: Thinking about a need for change Lasts up to six months Nursing Actions: Assess perceived barriers Emphasize pros over cons Provide health care education Discuss a time in the future to take action TTM Stage: Preparation Preparation stage: Preparing to change Usually within one month Nursing Actions: Discuss ways to prepare for change Determine what may need to be bought, altered or removed in order for change to occur TTM Stage: Action Action stage: Actively making the change Last up to six months Nursing Actions Offer encouragement Discuss change maintenance strategies Show support if there is a relapse back to the old habit TTM Stage: Maintenance Maintenance stage: Choosing to continue in the new behavior Working to prevent relapse Nursing Actions: Keep in touch in person or by phone Offer continued encouragement TTM Stage: Termination Termination stage: complete behavior change and no temptation to return to the old behavior Change Process Steps Conscious Raising increases awareness Dramatic Relief increases emotion Self-reevaluation assess self-image Environment reevaluation assess society image Stimulus control prompts Self Liberation self commitment Social liberation empowerment Counter conditioning alternatives Contingency management reinforcements Helping relationships social support Case Study 76 year old man with multiple co-morbities: CHF, chronic obstructive lung disease, diabetes On admission: overweight, depressed, elevated blood sugar, elevated blood pressure, 4+ pitting edema The Problems The patient: Not weighing self Not doing daily blood sugars Smoked Poor diet Reliance on Medical System High reliance on medical system to cure Transference of reliance to his wife to: Cook Give medications Blood sugar Wife had multiple medical problems: increasingly difficult to care for husband Case Study Plan Assess patient awareness of negative behaviors Consciousness raising Education of need to care for self Patient was in the stage of contemplation Case Study Plan Immediate health management issues: Dietary restriction of salt Self-management of daily blood sugar Weighing self daily Change of medications (NP) Moments of Frustration For weeks, the patient would not care for self. Clinicians increasingly frustrated! Case Study Plan Dramatic relief Past, present and future consequences Pros and cons Progress At 9 th week of care, the patient stated: I knew you were coming and so I figured I better do this I cut down on the salt too! Weight and blood sugar log had been completed Action Stage Patient had entered the action stage There were occasional lapses in self care At each visit, nurses Offered support and encouragement Discussed barriers and strategies to maintain change Case Study Outcomes This paradigm case became the jumping board for a renewed sense of enthusiasm in the clinical team! Clinical Team Outcomes Change in nurses and therapists: Enhanced knowledge of change Understanding that change takes time Greater number of change strategies Increased interest in motivating patients to change Increased team communication Increased patience with elderly patients Cardiac Life Outcomes Of the first 90 discharges from Cardiac Life 36 discharges to self care (40%) 15 hospitalizations for CHF symptoms (16%) 23 discharges to hospice (25%) 12 hospitalizations for other (13%) 4 deaths (4%) Nursing Implications Consider the use of TTM as a foundational change theory Promote TTM in settings where patients are seen over a long period of time (i.e. home care) Educate nurses and nursing students on TTM Research Needs Research needs: Efficacy of TTM in home care Effect of TTM on nursing satisfaction Multi-cultural usefulness of TTM Conclusion TTM appears appropriate for the home setting: Emphasis that change takes time is appropriate for the older adult Stages of change provide focus for the team in care planning Potpourri of change strategies Research of TTM in home care is warranted Contact Information Wyona M. Freysteinson, MN
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