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
Ⅰ．What is the EASE Program® Version 3.0?
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:
“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 in 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
1)
EASE is a structured program
EASE is a 6-step structured patient-education program. These steps are
outlined in section IV: EASE Program® Version 3.0 Action Plan. Here, the
term “structured”
specifically refers to the multilayered nature of its action plan, wherein
specific interventions are prescribed. As a result, the manner in which
the education program should be carried out is clearly conveyed.
The advantage to using EASE lies in the precise delineation of a subject’s
real situation based on an accurate interpretation of empirical data.
2)
EASE brings to light key issues of daily living
EASE turns the spotlight not on medical data such as test results, but
on the key issues of daily life that matter most to the subject.
When implementing EASE, the 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. EASE strives to highlight
what matters most to the subject in their life.
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 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,
it becomes possible to unravel the most significant problems in their daily
life. The healthcare professional can then discern which matters must be
addressed for the subject 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, 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 building trust between the subject and healthcare professional.
3) EASE is backed theoretically by health behavior models
Many patient education programs are criticized for not implementing theory.
In contrast, 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.
4)
EASE is based on a variety of research findings
The EASE methodology is based on extensive research. 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.”
Further, 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?’” Based
on these results, a nurse’s manner of speaking to the subject is modulated
when EASE is deployed. This adaptation is prescribed under “Step 2-3: Linking
life purpose with life’s problems.”
As described above, evidence-based lessons derived from quantitative research
are added 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.
5)
EASE is a reformulation of cognitive behavioral therapy
Cognitive behavioral therapy (CBT) 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 CBT, its effectiveness in inducing behavioral modification
is greatly enhanced. In the context of CBT, strategies may be used to achieve
goals. As such, CBT 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.
Ⅲ．Action Plan Premises
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:
1) Situation-specific
changes may be made
In this action plan, the sequence and components of each step may change
along the way to adapt 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.
As
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
subject.
2) Each step purposefully
proceeds toward goals
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.
3) The steps are
organically linked
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.
4) EASE functionalities
are systematically integrated
In
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
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.
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
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.
Step1. Assessment, including the appropriateness of
medical treatment
Step2. Defining a problem and verifying the
importance of a solution
Step3. Setting behavioral goals and verifying self-efficacy
Step4. Choosing strategies
Step5. Implementation
Step6. Evaluation/Comments
[References]
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
Shoin, Tokyo
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
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