Professor Michiyo OKA, RN, Ph.D
Gunma University Graduate School of Health Sciences
3-39-22 Showa-machi, Maebashi, Gunma,
Ⅰ．What is the EASE Program® Version 3.0?
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®.
Version 3.0 can be described as follows:
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.”
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.
EASE became a registered trademark on January 18, 2013.
Ⅱ．The Advantages of EASE
EASE is a structured program
is a 6-step structured patient-education program. Here, the term “structured”
specifically refers to the multilayered nature of its action plan, which prescribes
specific interventions. As such, the manner in which they should be carried out
is clearly conveyed.
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 brings to light key issues of daily living
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.
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
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.
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.
3) EASE is theoretically backed by health behavior models
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).
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
EASE is based on a variety of research findings
EASE methodology is based on extensive research results. For example, research
has shown that patient life-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.”
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.”
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.
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.
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.
EASE is a reformulation of cognitive behavioral therapy
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.
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
Ⅲ．Action Plan Premises
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
changes may be made
this action plan, the sequence and components of each step may change along the
way to conform to the subject’s particular 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.
such, it may be desirable for the healthcare professional to alter their manner
of speaking to suit the subject’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
2) Each step purposefully
proceeds toward goals
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
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.
3) The steps are
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.
4) EASE functionalities
are systematically integrated
EASE, the functionality of each step not independent of the other steps. The
program in fact integrates the collective 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.
5) EASE functionalities
may be deployed spirally
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.
6) Efficacy may vary
depending on the professional learning climate (PLC)
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.
Ⅳ．EASE Program® Version 3.0 Action Plan
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.
Step1. Assessment, including the appropriateness of
Step2. Defining a problem and verifying the
importance of a solution
Step3. Setting behavioral goals and verifying self-efficacy
Step4. Choosing strategies
Joboshi H, Oka M. (2016) Effectiveness
of an educational intervention (the Encourage Autonomous Self-Enrichment
Program) in patients with chronic kidney disease: A randomized controlled
trial.Int J Nurs Stud. 67:51-58. doi: 10.1016/j.ijnurstu.2016.11.008. 2017
Oka M, ed. (2018) Nursing to
encourage behavior change: EASE program to support patients' purpose of life, Igaku
Oka M, Takahashi S, Tsukamoto
S.(2019) Encourage Autonomous Self-Enrichment (EASE) program Helped a
Participant Give Birth:-Focus on the connection of life and difficulties. Journal
of the Japan Academy for Health Behavioral Science, 34(1), 33-40