One of my health heroes – James Prochaska, PhD, a professor of clinical psychology at the University of Rhode Island and coauthor of the book Changing for Good: A Revolutionary Six-Stage Program for Overcoming Bad Habits and Moving Your Life Positively Forward – was one of the keynote speakers at the recent American College of Nurse Practitioners 2012 Conference.

Prochaska’s book plays a major role in how I think about behavior change and how I approach this often-difficult aspect of health care with my patients. His workshop at AANP 2012 was about using the Transtheoretical Model (TTM) of behavior change in practice.

Let’s review. The TTM states that there are five stages of behavior change. These include:

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  • Stage 1 – Precontemplation, in which patients are not yet ready to make a change
  • Stage 2 – Contemplation, in which patients intend to make a change, but are still ambivalent
  • Stage 3 – Preparation, in which patients are ready to start the change
  • Stage 4 – Action, during which patients have begun to make the change
  • Stage 5 – Maintenance, which occurs after patients have already made the change and are working towards keeping up the new behavior

The ultimate goal of TTM is for the healthy behavior change to become automatic for the patient, so they do not have to think about the behavior for it to occur. In successful patients, the healthy behavior has become a permanent part of life.

The majority of the patients we see, about 80%, are in the pre-contemplative stage, according to Prochaska. But the benefit of TTM is that it works in all patients, regardless of their stage. Other models, such as the Banduras Self Efficacy Theory, works only among patients who are already motivated, or motivational interviewing, which can be very effective but focuses only on patients ready for the action stage.

In his lecture, Prochaska emphasized the importance of focusing on meeting patients at whichever stage they are currently in. He described a sign hanging in his waiting room that reads, “Wherever you are at, we can work with that.” A simple strategy for accomplishing this is describing the TTM stages or having the patient read literature on the topic and then asking them with which stage they identify. 

In order to keep our patients coming back for assistance with behavior change, we cannot simply set them up for failure. Work with them to set realistic goals. Think about assigning simple actions for those who are not ready to completely change their behavior just yet. Keep in mind that increasing the number of positive aspects associated with changing a behavior is a necessary antecedent to action. 

A patient’s progression from the pre-contemplation stage to the action stage is a function of approximately one standard deviation increase in their perceptions of the pros associated with a healthy behavior change, and a one-half of a standard deviation decrease in their perception of associated cons, Prochaska explained.

Be open and honest. If you sense a patient becoming defensive, address this immediately and express that this is not your intention. Also, realize that progressing from one stage to the next – pre-contemplation to contemplation, for example – is a success, regardless of whether the final goal has been achieved. Remember to treat it like one.

Julee B. Waldrop, DNP, FNP, PNP, is the Director of the MSN-DNP Program and an associate professor at the University of Central Florida. She provides health care to children at a local community health center.


  1. Prochaska J, Norcross J, DiClemente C. Changing for Good: A Revolutionary Six-Stage Program for Overcoming Bad Habits and Moving Your Life Positively Forward. New York; 1995: William Morrow Paperbacks.
  2. For more information, visit