As a professionally trained nurse, I know how seemingly small health choices add up over time to better or deteriorating health. There is good and hard news in this reality. The good news is that many of our daily health decisions are within our own control. We can decide to eat this or not eat that. We can decide to move around instead of watch another 30 minutes of television. We can decide to wear our seatbelts every time we get in a car. We can take the proper dosage of a prescription and so on. The hard news is that if we are generally healthy, no one has more control over our personal health status than we do.
At Aetna we work directly with millions of people every year who need or want to be as healthy as they can be. Because everyone’s path to health is a little bit different, our nurses act as guides and health coaches. In every situation, at least some portion of progress is dependent on individual health choices and personal motivation.
The short answer is that it comes from inside. The long answer is that the motivation behind health choices varies by individual. The wrong answer is to try to cajole anyone into doing something they aren’t going to do even if they know it’s good for them. To be successful advocates for health, we know we have to understand where a person is coming from before we can begin to help.
For example, if one of our nurses makes a call to someone with a chronic health condition or in rehab after surgery, we don’t start by challenging them on whether they are following their doctor’s orders.
Instead, we ask how the person is doing. We ask what their priority is, what they feel good about, and where they want to be with their health and their lives. We listen. Then we take steps to help them.
As clinicians, we need to identify what motivates a person to take action or change, and what barriers are preventing them from doing so. Nurses everywhere – in health care companies like Aetna, in hospitals, in medical offices and outreach programs – are using motivational interviewing to reach people where they are. They understand that many of the factors influencing our health are outside of the care provided by medical practitioners.
Hal Paz, Aetna’s chief medical officer, describes it this way, “In many cases our own behaviors – led by the decisions people make about smoking, exercise and diet — have a greater impact on life expectancy than the care a person gets in a doctor’s office or hospital. Alcohol and drug use and even driving habits also have a significant impact on health and lifespan. Studies estimate that behavioral causes are accountable for about 40 percent of the years lost to premature death.”
Doctors’ orders, compliance, adherence…all sound so negative. It doesn’t have to be that way.
Those trying to recover from illnesses or injuries, or manage chronic conditions like diabetes or heart disease, have likely been advised by a health care professional. Instructions typically include “take your medications,” “watch what you eat,” “get in some exercise,” “stop smoking,” or avoid certain activities. Practitioners trust that following or complying with this advice will result in more healthy days. Not complying could result in slower recovery, poorer health, complications, and the need for more health care.
From the practitioner’s point of view, the choice seems pretty straightforward. Yet, a lot can happen between getting “the orders” and the choices you actually make. Practitioners need to remember: The health choices people make are limited to the choices people have.
As care providers, we have to explore and understand what choices are available to each individual , and work within the reality of their lives to help them achieve healthy, happy days.
We need to remember: The health choices people make are limited to the choices people have.
What does this look like?
In their coaching roles, our nurses find out what will motivate a person to take the steps they can to have more healthy days. Someone might want to stay active to enjoy their grandkids someday, while another person may want to learn to walk again or lose weight before a big family event. (Weddings are always big motivators!) Regardless of what is motivating them, we meet people where they are and figure out how they can get where they want to be.
We do this by asking questions and listening. If someone isn’t exercising, a nurse can ask what kind of exercise the person might enjoy to learn how it could be worked into their life. The next step is to help the person voice their own specific goals.
Maybe someone can’t afford a gym or exercise class, or they feel uncomfortable exercising in front of others. Then the nurse can talk about walking. But what if their neighborhood doesn’t include safe walking trails or even safe areas? That conversation might turn to exercises people can do in their homes, or simple things like taking the stairs instead of elevators and parking their car at the farther end of the lot whenever they go somewhere.
If someone hasn’t been taking their medicine, the nurse can talk with them to understand why. Did it cost too much, even with insurance? A nurse can ask the primary care practitioner or pharmacist to consider a less expensive but equally effective drug, or connect the person with discount programs offered by drug manufacturers or patient advocacy groups. Did they stop taking the medicine because of side effects? The nurse can talk about ways to lessen the side effects, or help them ask their practitioner about alternatives. Are they having trouble getting to the pharmacy? A mail order pharmacy or delivery may be solutions. Maybe they are afraid to use a self-injected drug, and a home care nurse can come help them get comfortable with the process.
Nurses look for psychological barriers too. Depression can be a major factor preventing people from fully recovering or successfully dealing with a chronic condition. In those cases, we can connect people to a variety of services to assist.
We need to widen the safety net
The health care system is as complex as the people it serves. In the past, the patient was often the only common thread between doctors, pharmacies and health centers. New technology can help the different players get and stay more connected, but it will take a concerted effort to truly help the patient being served by different parts of the system.
Here’s an example: If a prescription is never picked up, or refused because of cost, a pharmacist could let the prescribing doctor know so the patient can be offered alternatives. Practitioners could tell a patient to call rather than just stop the medicine if they have side effects. Hospitals can incorporate depression screening into their discharge process to prompt a follow up by the primary physician.
We’ve seen firsthand how effective it is when we meet people where they are to understand the motivation behind their health choices. The first step is helping them focus on why they want to feel better. The second step is helping them get started.