EASE program®
「Encourage Autonomous Self- Enrichment program」
Professor Michiyo OKA, RN, Ph.D
Gunma University Graduate School of Health Sciences
3-39-22 Showa-machi, Maebashi, Gunma, 371-8514 Japan
E-mail: michiyooka@gunma-u.ac.jp
The EASE Program® (hereafter, “EASE”) is short for the official name, the Encourage Autonomous Self-Enrichment Program.Thus, EASE is an acronym. The officially titled the Encourage Autonomous Self-Enrichment Program is more simply referred to using the acronym EASE; that is, the EASE Program®.
EASE Version 3.0 can be described as follows:
“It is a program that clarifies certain key issues of daily living surrounding a subject’s health, disease,or lifestyle, draws on implements such as health behavior models to better comprehend and assess the subject, and achieves both behavioral and cognitive modification by mobilizing cognitive behavioral therapy as a guiding philosophy and methodology.”
Currently available in its third version, EASE’s history can be traced as follows. In 1997, Version 1 originated in the form of an academic thesis that proposed a behavioral modification program. Version 2 was created in 2005 as a response to numerous expressions of interest in bringing it to life. An action plan was thus established to outline the steps needed to execute the program. Following widespread implementation at various sites, it was eventually christened EASE®. This was intended to raise its profile above other nondescript schemes that were generically labeled as behavioral modification programs. While our current focus is on EASE® Version 3.0, further updates are forthcoming.
Incidentally, EASE became a registered trademark on January 18, 2013.
EASE is a 6-step structured patient-education program. Here, the term “structured” specifically refers to themultilayered nature of its action plan, which prescribes specific interventions. As such, the manner in which they should be carried out is clearly conveyed.
The advantage to using EASE can be found in its precise delineation of a subject’s real situation based on an accurate interpretation of empirical data.
EASE turns the spotlight not on medical data such as test results, but on the key issues of daily living that matter most to the subject.
When implementing EASE, the first priority should not be the subject’s problems. Rather, the main approach should involve their outlooks on health, disease, and lifestyle. Instead of listening through the stethoscope, EASE urges the healthcare professional to listen to the subject, thus relegating medical data such as test results to the background rather than placing them on the center stage. EASE strives to highlight what matters most to the subject in the business of living.
For example, instead of typecasting the subject through medical jargon (e.g., “a patient with an HbA1c profile in the 8% range for over 6 months”), the healthcare professional may identify them as “the father of 4 children, who by all means wants to work as best he can until he retires.” This latter description explicitly demonstrates the subject’s value as an individual in the eyes of the healthcare professional.
By not viewing the subject exclusively through the prism of medical data and thereby unraveling the most significant problems in their daily life, the healthcare professional can discern all important and necessary matters they need to live with dignity.
The above task is specifically accomplished through “2-1) Defining life purpose” under “Step 2: Defining a problem and verifying the importance of a solution.” The subject’s life purpose takes precedence in an EASE-oriented framework as reflected by the key issues of daily living that they deem significant. Support thus begins by respecting their preferred way of living. This respect is essential for optimizing trust between the subject and healthcare professional.
Many patient education programs are criticized for not implementing theory. Unlike those programs, EASE features a theoretical framework underpinned by three principal theories that are applicable to real-life situations, including Bandura’s Self-Efficacy Theory, Pender’s Health Promotion Model (HPM), and Cox’s Interaction Model of Client Health Behavior (IMCHB).
For instance, in “Step 1-1) Validating the therapeutic approach” under “Step 1: Assessment, including appropriateness of medical treatment,” the program gauges the propriety of certain behaviors adopted by the healthcare professional (e.g.,whether specialized terminology was excessively employed during patient education). This area of assessment can be viewed as analogous to “professional/technical competencies” under “(3) healthcare professional interaction factors” in Cox’s IMCHB. Once goals have been established, self-efficacy in their attainment is verified through “Step 3: Setting behavioral goals and verifying self-efficacy.” This process draws on self-efficacy theory, HPM’s self-efficacy principle, and the IMCHB’s cognitive appraisal process.
The EASE methodology is based on extensive research results. For example, research has shown that patientlife-satisfaction levels are most influenced by self-determination. Therefore, when implementing EASE,patients decide on their behavioral goals and the various strategies they will put into action. This principle is the basis for “2-1) Defining life purpose” under “Step 2: Defining the problem and verifying the importance of a solution.”
Further, actual case studies using EASE have reported the following: “When asking about their life purpose, it is easier to obtain an answer when the question is rephrased as: ‘What do you usually consider important in life?’” A nurse’s manner of speaking to the subject is modulated when EASE is deployed based on the results of those case studies. This adaptation is prescribed under “Step 2-3: Linking life purpose with life’s problems.”
As described above, evidence-based lessons deductively derived from quantitative research are absorbed into practice when using EASE. Conversely, modifications are inductively derived from actual case studies that implement the program. EASE’s structure incorporates this cycle of research-based deductions and inductions, thus constantly making the most of various research findings.
There have also been advancements through EASE-related research and discourse. Taken together, there were more than 100 EASE-based verbal presentations at academic societies and published academic journal articles as of 2008. Further, EASE is now deployed at healthcare facilities throughout Japan.
Moreover, a randomized controlled trial (RCT) was conducted on different interventions implemented among two groups of chronic renal disease patients (i.e., one using a previous patient education program and the other using EASE). When compared to the group receiving conventional patient education, results showed that the EASE group registered significantly higher levels of both self-efficacy and self-management behavior. Notably, this highly credible and respected research report was published in the nursing journal with the greatest professional impact in Japan in 2006.
Cognitive behavioral therapy is widely recognized in both the West and Japan for its efficacy in taking advantage of cognitive faculties, thus arriving at solutions for a subject’s psychosocial problems. This is a powerful method of supporting cognitive and behavioral modifications that nurses can also learn.
Since EASE draws on cognitive behavioral therapy, its effectiveness in inducing behavioral modification is greatly enhanced. In the context of cognitive behavioral therapy, strategies may be used to achieve goals. As such, cognitive behavioral therapy is the employed methodology in EASE’s “Step 4: Choosing strategies.” The five main methods involved are as follows: linkage to life purpose, self-monitoring, behavioral reinforcement, step- by-step, and peer learning.
EASE is deployed by conducting Steps 1 to 6 of the action plan, which encapsulates a roadmap for navigating the program in a user-friendly format. In real-life executions, these steps do not necessarily follow each other in numerical order,nor does the action plan prescribe a specific sequence that must be followed. Further, the steps are not isolated from one other, but instead exist in conjunction to form an integrated system. Hence, this action plan pivots on the following premises:
In this action plan, the sequence and components of each step may change along the way to conform to thesubject’sparticular circumstances. For example, if the subject proactively seeks behavioral change, then there is no need to probe their life purpose or discern what matters most to them during “Step 2: Defining a problem and verifying the importance of a solution.” Even without the healthcare professional’s verification, the subject’s motivation may grow stronger. In such cases, “verifying the importance of a solution” may be omitted.
As such, it may be desirable for the healthcare professional to alter their manner of speaking to suit thesubject’s circumstances. For example, instead of merely asking “What do you consider most important in your life?,” the subject’s life purpose may be crystallized through alternative questions, such as “What do you think makes life enjoyable?” The program is made to succeed not only through how the health professional speaks, but also by modifying their wordage to suit the subject.
Each step does not simply enumerate necessary actions. Rather, examples are provided to illustrate how each step achieves certain goals. Thus, the program encourages a manner of speaking that is consistent with those goals during each step.
For example, “Step 2: Defining a problem and verifying the importance of a solution” aims to bring to light any problems the subject may perceive relating to their medical treatment and verifies the importance of resolving those problems. The healthcare professional should thus absolutely avoid any criticisms of the subject’s perception of those problems during their interactions.
The action plan entails that numerous steps and subsidiary procedures are organically linked. For example, verifying the importance of a solution as outlined in Step 2 is related to the outcome of Step 5, among various others.
In EASE, the functionality of each step not independent of the other steps. The program in fact integrates thecollective functionalities of all constituent steps into one system. As such, modification of the subject’s behavior can not immediately begin simply because all data from Step 1 have been collated. Rather, cognitive and behavioral modifications can only be contemplated after the results from other steps have also been comprehensively integrated.
Step 2 does not necessarily have to follow Step 1 in a strict linear sequence. Program functionalities may sometimes be deployed by taking a spiral route. For example, depending on the subject’s circumstances, situations may arise in which advance consultations should be held based on the behavioral goals called for in Step 3. The program can, therefore, advance at the pace most suitable to the subject by allowing processes to flow back and forth in a spiral pattern.
The PLC may be defined as “a pervasive attitude or aura that a professional is imbued with, underpinned by specialized knowledge and experience and conducive to successful patient education.” In concrete terms, this involves believing in and respecting the subject, creating a space in which the subject can feel relaxed and comfortable, and manifesting concern toward the subject.
For example, it is preferable to ask the subject the following in Step 2: “What kind of behaviors do you think would be good for you?” However, depending on the questioner’s tone or facial expression/body language, the subject may feel as if they are being interrogated. It is thus essential that healthcare professionals maintain an effective PLC based on the manner of speaking prescribed in the action plan.
The EASE action plan deploys various processes subsumed within six steps. Here, subsidiary processes are prescribed in each step, while points to bear in mind when executing them are also highlighted. Further, the program literature provides examples of appropriate speech for each step and process.
Step.1.Assessment, including the appropriateness of medical treatment
Step.2.Defining a problem and verifying the importance of a solution
Step.3.Setting behavioral goals and verifying self-efficacy
Step.4.Choosing strategies
Step.5.Implementation
Step.6.Evaluation/Comments
