Patient S is a White woman who is 48 years of age. At a recent routine physical examination, she learns that her fasting blood glucose is 118 mg/dL. With a height of 5 feet 5 inches and a weight of 162 pounds, her BMI is 28, placing her in the category of overweight. Her physician refers her to Nurse A, a diabetes educator, for counseling and education on the prevention of diabetes, instructing her to keep a food diary and bring it to the appointment.

Nurse A begins the encounter by taking steps to develop a collaborative relationship with Patient S, first performing a learning needs assessment by asking her what she already knows about prediabetes and its risks and treatment. Nurse A determines what she wants to learn and what her goals are. Next, the patients' social situation and support system are assessed, including how family, work, and other obligations affect her lifestyle choices. Nurse A inquires regarding past smoking or alcohol use. Finally, the nurse asks what, if anything, the patient has started doing, or would like to start doing, to help herself prevent diabetes.

Patient S's physician had given her basic information on prediabetes and advised her to lose weight and begin exercising. The patient read the booklet on prediabetes and seems to have a reasonable understanding of her condition and the recommendations for treating it. However, she says she feels overwhelmed with the thought of making major lifestyle changes. She says, "I know I need to make changes, but I just can't get myself to do it." To decrease her anxiety and build self-efficacy, Nurse A replies, "The thought of change can be scary, but if you really want to, I am confident we can find some ways to help you do it."

This is a good time to assess the patient's readiness to change. Although she has some reluctance, Patient S rates her readiness to change as 8 on a scale from 0 to 10. She states that she will be going on vacation next week but will feel ready to make changes when she returns.

The next step is to negotiate an agenda for the encounter. Given that Patient S understands the basic treatment recommendations for prediabetes, the nurse asks what she would like to begin working on first. She says that she knows she needs to lose weight and wishes she could. With her permission, Nurse A takes the opportunity to educate her on the research that shows she can prevent or delay diabetes onset by losing 5% to 7% of her current body weight, which is 8 to 11 pounds. To help Patient S make realistic weight loss goals, the nurse asks, "Would you say that losing 8 pounds is something you could work on?" The patient is surprised that she only needs to lose 8 pounds; she had expected more than that. Nurse A supports the idea of greater weight loss eventually but suggests starting with 8 pounds and working from there. The nurse explains that her success in losing a few pounds at first increases the likelihood that she can lose more later.

While Patient S agrees that an 8-pound weight loss is reasonable, she remains ambivalent about making the necessary lifestyle changes. She says, "I really hope I can do this, but I'll probably never maintain it." The nurse recognizes this as change talk and takes the opportunity to explore it by asking, "Can you name three benefits you would enjoy if you did lose 8 pounds?" Patient S replies that she would drop a dress size, she would feel good about preventing diabetes, and it would motivate her to continue losing more weight.

Now that the patient has a realistic goal to lose 8 pounds, it is time to make an action plan that specifies the steps she will take to meet her goal. Nurse A starts by reviewing the key tenets of weight loss: eating less, lowering fat and calories in her diet, increasing fiber intake, and/or increasing exercise. The nurse demonstrates the plate method to the patient as a simple model for healthy eating and asks, "Which of these would you like to start working on today?" Patient S replies that she would like to do all of them, but says she is afraid it will take too much time to do all of these things. Once again, this is recognized as change talk, and Nurse A replies, "So is it safe to say that you think making some changes is worth a try?" With her consent, Nurse A begins helping Patient S specify her action plan by asking to review her food diary with her. Together, the nurse and patient determine that:

Patient S's food diary reveals areas in which she can capitalize on healthy choices she is already making. Nurse A points out that she eats fruits, vegetables, and whole grains, eats breakfast, uses fat-free milk, and does not eat large amounts of saturated animal fat. Collaboratively, the two formulate a list of possible dietary changes based on her diary. Of these things, Nurse A asks her to pick two or three that she would like to start working on right away. She makes the following choices:

Next, Patient S writes action plans for each of her behavior change choices. Nurse A assists the patient to begin formulating an action plan for her first choice by asking the following questions:

Patient S's completed action plan is to eat one-half cup whole-grain cereal or six whole-grain crackers every day in place of refined carbohydrate snacks.

The next step in making an action plan is to measure the patient's confidence in her ability to carry out the plan and to help her make modifications if needed. Patient S is asked to circle a number on a scale of 0 to 10 rating her confidence. She circles the number 6.

A confidence rating of 7 or more indicates that a person is reasonably confident in his or her ability to carry out the action plan. Because Patient S rated her confidence level as 6, it indicates that this action plan is probably not achievable for her. Nurse A asks her what would be more realistic, and she replies, "If I could just have a sweet treat on the weekend!" The nurse prompts her to change the "how often" part of her action plan from "every day" to "five days per week." With this modification, Patient S rates her confidence in the action plan as 9. Obviously, refraining entirely from sweet treats is desirable, but if she does not have the self-efficacy to do this, Patient S's action plan has a high risk for failure. It is better for her to experience success with small steps and build from there with future action plans.

If time allows, the nurse may continue helping the patient formulate action plans for her other chosen behavior changes. Her readiness to set a goal and make an action plan for exercise should be assessed using the same methods. With many people, especially if they are overwhelmed or lack self-efficacy, it is best to be conservative in the number of action plans they make initially. Too many action plans may be unrealistic. Usually, two or three action plans at a time is reasonable. Remind patients that when they achieve one action plan, they can begin to add more and build on their success over time.

Although there is not time for Nurse A to help Patient S formulate action plans for all of her chosen behavior changes, she has empowered her to make her own action plans. Nurse A asks the patient to report her subsequent action plans by phone, email, or at a future visit.