Brief Action Planning to Facilitate Behavior Change and Support Patient Self-Management

Question 2: Scaling for Confidence

After a commitment statement has been elicited, the second question of BAP is asked. “How confident or sure do you feel about carrying out your plan on a scale from 0 to 10, where 0 is not confident at all and 10 is totally confident or sure?” Confidence scaling is a common tool used in behavioral interventions, MI, and chronic disease self-management programs [17,51]. Question 2 assesses an individual’s self-efficacy to complete the plan and facilitates discussion about potential barriers to implementation in order to increase the likelihood of success of a personal action plan.

For patients who have difficulty grasping the concept of a numerical scale, the word “sure” can be substituted for “confident” and a Likert scale including the terms “not at all sure,” “somewhat sure,” and “very sure” substituted for the numerical confidence ruler, ie, “How sure are you that you will be able to carry out your plan? Not at all sure, somewhat sure, or very sure?” Alternatively, people of different cultural backgrounds may find it easier to grasp the concept using familiar images or experiences. For example, Native Americans from the Southwest have adapted the scale to depict a series of images ranging from planting a corn seed to harvesting a crop or climbing a ladder, while in some Latino cultures the image of climbing a mountain (“How far up the mountain are you?”) is useful to demonstrate “level of confidence” concept [54].

Skill 4: Problem Solving for Low Confidence

When confidence is relatively low (ie, below 7), we suggest collaborative problem solving as the next step [8,51]. Low confidence or self-efficacy for plan completion is a concern since low self-efficacy predicts non-completion [8]. Successfully implementing the action plan, no matter how small, increases confidence and self-efficacy for engaging in the behavior [8].

There are several steps that a clinician follows when collaboratively problem-solving with a patient with low confidence (Figure 1).

• Recognize that a low confidence level is greater than no confidence at all. By affirming the strength of a patient’s confidence rather than negatively focusing on a low level of confidence, the provider emphasizes the patient’s strengths.

• Collaboratively explore ways that the plan could be modified in order to improve confidence. A Behavioral Menu can be offered if needed. For example, a clinician might say something like : “That’s great that your confidence level is a 5. A 5 is a lot higher than a 1. People are more likely to have success with their action plans when confidence levels are 7 or more. Do you have any ideas of how you might be able to increase your level confidence to a 7 or more?”

• If the patient has no ideas, ask permission to offer a Behavioral Menu: “Would it be ok to share some ideas about how other patients I’ve worked with have increased their confidence level?” If the patient agrees, then say... “Some people modify their plans to make them easier, some choose a less ambitious goal or adjust the frequency of their plan, and some people involve a friend or family member. Perhaps one of these ideas seems like a good one for you or maybe you have another idea?”