Stage of Change and a Night-Shift Worker With Prediabetes
Mr. T., 45, is referred by his primary care provider after a lab result shows A1c 6.1% and BMI 34. He works 12-hour night shifts as a warehouse supervisor, sleeps about five hours, and drinks two energy drinks per shift. He says, 'I know I should exercise. I'm just exhausted. I'll start when things calm down.' He has joined a gym three times and quit within two weeks each time. On a 0-10 scale he rates the importance of changing at 8 and confidence at 3. He can name several benefits of activity and several barriers, including knee soreness and irregular hours. He has not set a specific activity plan and does not currently exercise. He is not interested in 'another program that tells me to be at the gym at 5 a.m.' You have 30 minutes.
1. What stage of change is Mr. T. in? Justify using at least two stage criteria and explain why the other stages do not fit.
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Mr. T. is in contemplation, not precontemplation or preparation. Contemplation criteria: he acknowledges the problem ('I know I should exercise'), weighs pros and cons, and has not taken sustained action in the past six months. He is not precontemplation because he is not denying the issue or defensive; he names benefits and a timeline. He is not preparation because he has no specific plan, no start date, and low confidence; 'when things calm down' is not a concrete commitment. He is not action because his gym attempts lasted under two weeks and he is not currently exercising. His importance rating of 8 shows the issue matters; confidence of 3 shows the gap is efficacy and planning, not motivation. The prior quit attempts are data, not failure: they suggest the plans were too ambitious or poorly matched to night-shift fatigue. Stage placement matters because a contemplation-matched response explores ambivalence and builds confidence, while an action plan would likely trigger defensiveness or another short-lived attempt.
2. Which processes of change and theoretical constructs would you prioritize, and why? Give examples of what you would actually say or do.
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Prioritize processes that support contemplation and early preparation: self-reevaluation ('What would be different if you had more energy at your daughter's game?'), environmental reevaluation ('How do night shifts affect your eating and activity?'), and self-liberation ('What small commitment are you willing to make?'). Use consciousness raising briefly with his A1c, not as a scare tactic. Build self-efficacy through mastery: a 5-minute walk after one shift, not a gym program. Use vicarious models, such as other shift workers who walk in small blocks. Explore decisional balance without stacking the deck: 'What do you get from staying as you are? What would change?' Address outcome expectations: he may believe exercise must be 60 minutes at a gym to count. Correct that with 'any 10 minutes counts' only if accurate for his health. Use helping relationships, such as a coworker walk partner. Plan for knee soreness with low-impact options and a referral to physical therapy if pain limits activity. Set a review in one week; confidence should rise before the plan expands.
3. What plan would be mismatched to his stage, and what would a stage-matched first step look like?
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A mismatched plan would be: join a gym, go five mornings a week at 5 a.m., and track calories, despite his night shifts, knee soreness, and confidence of 3. That plan assumes preparation or action and treats low confidence as a motivation problem. It would likely produce another two-week quit and reinforce 'I can't stick with it.' A stage-matched first step is a small, self-selected experiment: 'Would you be willing to try a 5-minute walk after two night shifts this week, just to see how it affects your energy?' Or 'What is one swap for the second energy drink?' Ask him to choose. Use an if-then plan: 'If I finish a night shift and feel wired, then I walk to the end of the block before bed.' Review the experiment without judgment. If he does it, attribute success to him and increase slightly; if not, problem-solve the barrier and adjust. The goal is to build evidence that change is possible, not to win compliance.