Supporting our patients to become more activated and engaged 29 th November 2016

1. Supporting our patients to become more activated and engaged 29th November 2016

2. In pairs discuss what you do on a daily basis that supports your patients to feel confident to self care

3. On a scale of 1-10 how ‘activated’ are the majority of your patients currently?

4. Lightbulb moment

5. Outcomes for people not pathways

6. By the end of our session you will: • Understand why some patients are relatively easy to work with and others much more challenging • Have clearer insight that shows you where your patients are currently • Thought about how and where to use motivational interviewing and the stages of change • Know that ambivalence about changing is natural and develop some techniques on how to work with this • Started to think about how we can respond constructively when a person is 'resistant’ or ‘stuck’ – and know what to examine in our own practice when this happens • Thought about some ideas on how we might deliver care in a different way

7. What is Motivational Interviewing (MI) ? “a goal directed, patient-centered counseling style for eliciting behavior change by helping people to explore and resolve ambivalence” (Miller & Rollnick, 2002) In pairs jot down on a post-it what this means to you

9. Motivational Interviewing • Model of skills and techniques to help patients take more control and change • Person centred, directive and non confrontational • Uses reframing and silence to reveal: • Individual personal strengths • Discrepancy between sated goals /values and behaviours

10. Benefits of MI • Minimises resistance • Creates discrepancy and builds on discrepancy between goals and current behaviour (from patient’s perspective) • Explores and resolves ambivalence • Elicits “change talk” • Sets in motion the patients change potential

11. AmbivalenceStuck in the middle • Having inconsistent beliefs is a normal process and we all have them • If ambivalence is being expressed there is something to work with • Resistance (arguing, interrupting, blaming others, ‘yes buts’, voting with feet) should be expected & part of the process

12. Techniques for resolving ambivalence • Ask open ended questions • Affirm patients autonomy • Reflective listening • Summarise conversation

13. Unconsciously/incompetent we have all been in cars but we don’t actually know what it feels like to brake and change gear Consciously/Incompetent after some driving lessons we now realise what we don’t know Thinking about thinking ..Conscious/Competence 4-Box Thinking Model Unconsciously /Competent we are so familiar with driving that we are almost on auto pilot WITHOUT CHECKS BACK UP? Consciously/Competent we are at driving test level, we think about everything we do in the vehicle Today is about being in the moment and thinking about thinking

14. Reflection exercise The ‘problem patient’ ….. Write about a behaviour/problem you’d like to consider making a change to…. & Please don’t share this just yet While writing answer these questions on your worksheet • What do you think about this behaviour/problem? • What do others thinks about it? • Do you want to change anything? • What do you want to change but don’t….

15. Lightbulb moment

16. Task led Persuasive Content What we say Talking Active/passive Repetitive Rapport not needed Expert Patient led Contractual Process How we say it Listening Active/active Flexible & Skilful Rapport essential Collaborator

17. 4 Models of clinical care • Paternalistic • Parental role • Clinician decides whats best • Informative • Clinician gives information on Rx • Patient selects • Interpretive • Clinician helps patient explore their values and select Rx that best fits these • Deliberative • Clinician helps patient explore their HEALTH related values and choose best Rx based on these

18. Behaviour Change

19. The key stages of Change Prochaska JO and DiClemente CC. J Consult Clin Psych 1983;5:390-395.

20. Cycle of Change

21. Cycle of Change

22. Reflection exercise Go back to the behaviour/problem you wrote about earlier? Think about where do you consider yourself to be in the cycle of change with your behaviour/problem? Jot some thoughts down

23. Lightbulb moment

24. Mapping what we do at each stage

25. Change • Motivation – Why change? • Information – What to change? • Ability/Resources/Effort – How to change? • DO WE AS HCP’S GIVE THE RIGHT INFORMATION AT THE RIGHT TIME?

26. Lightbulb moment

28. Principle 1: Resisting the Righting Reflex • We want to make things right • With MI we don’t try to change the patients behaviour • Change comes from the patients intrinsic motivation • To succeed at MI resist the righting reflex – No fixing!

29. Principle 2: Understand the patients motivation to change • Patient’s belief in the possibility of change is an important element of motivation • Client, not you, is responsible for choosing and carrying out change • The why THEY want to change NOTE: Your belief in client’s ability to change becomes a self-fulfilling prophecy

30. Principle 3: Listen to your patient • Listen as much as you inform • Resistance should not be directly opposed • Invite new perspectives but don’t impose them • When it comes to behaviour change, the answers usually always lie within the patient – finding tem requires good listening skills

31. Principle 4: Empower your patients • Help patients EXPLORE how they can make difference • Support their hope that such change is possible and can make a difference • Facilitate the conversation – get the patient to think out loud

32. Time to practice Ones are Interviewees;Twos are Interviewers • Interviewee: Pick something in your life that is an issue or a challenge • Nothing will be disclosed about your exchange unless you do the disclosing • We want to know how you felt about the exchange/dialog • Interviewer :Try to solve your partner’s issue by giving pertinent information and advice addressing it. SWITCH Roles

33. Lightbulb moment

34. 2nd time around Interviewee: Using the same challenge as before • Interviewer:◦ Assess your interviewee’s stage of change◦ Listen and reflect without giving unsolicited advise Switch Roles Was there a difference in how the 2 exchanges felt, as an interviewee and as the interviewer?

35. Lightbulb moment

36. OARS: Basic MI skill • Ask Open-ended questions –not short-answer, yes/no, or rhetorical questions • 2. Affirm– comment positively on strengths, effort, intention • 3. Reflectwhat the person says – active/reflective listening use silence • 4. Summarise, draw together the persons own perspectives on change (use sparingly) OARS= Open-ended questions, affirming, reflecting, and summarising.

37. Change Talk – Examples Desire: I want to get healthier and feel better Ability: I could lose weight / stop smoking Reasons: I should lose weight / stop smoking because .... Need: I've got to lose weight / stop smoking COMMITMENT to Change: “I will lose weight / stop smoking ”

38. Motivation • Assess: • How important is it for you to change right now? • Improve/Enhance: • Create context: patient’s life goals • Review prior efforts, including lessons from successes and failures • Recognise your lack of power • Acknowledge your lack of power • Identify your patient’s strengths • Promote your patient’s power

39. Scaling Questions

40. On a scale of 0 to 10, how IMPORTANT is it for you to change right now? On a scale of 0 to 10, how CONFIDENT are you that you could make this change? 0 | 0 | 1 | 1 | 2 | 2 | 3 | 3 | 4 | 4 | 5 | 5 | 6 | 6 | 7 | 7 | 8 | 8 | 9 | 9 | 10 | 10 |

41. Building Confidence/Importance • Do little else… • Ask about the score… • Brainstorm solutions • Reviewing past successes and failures • Review personal strengths and supports • Hypothetical change – in the future

42. Affirming Statements • Directly affirming a patient can help build rapport and increase confidence • Notice signs of patient’s strengths and efforts and reflect them back • “That seems like a good thing for you to start with as you know how to …” • “I appreciate you taking the big step and coming here” • “You’re clearly a resourceful person to deal with the difficulties you have / way you’ve been feeling for so long”

43. Assessing readiness = importance & confidence • How importantis it to change X/Y behaviour?? Eg “On a scale of one (not very important) to 10 (extremely important), how important is it that you change your behaviour X?” If score = 7 (or above) reflect back to them that it sounds like changing behaviour X is important to them If below 7 – explore importance further See Importance /confidence ruler handout

44. Assessing readiness = importance & confidence • How confident are you about changing X/Y?? Eg “On a scale of one (not very confident) to 10 (extremely confident), how confident are you that you can change your behaviour X?” If score = 7 (or above) reflect back to them that it sounds like they are confident (they know how) to make the change If below 7 – work on building confidence

45. 3rd time around Interviewee: Using the same challenge as before • Interviewer: Using the ruler • ◦ Assess how important/Confident the change/ make change is to your interviewee right now ◦ Listen and find out why they are there where they are a 3 not a 6 /2 not 8 etc Switch Roles • How different did the conversation feel this time?

46. Lightbulb moment

48. Capture Think about the patients you serve. What challenges do your patients bring?

49. Capture Think about the patients you serve. What resources do they bring?

50. Capture Think about the patients you serve. How will you communicate this awareness in a manner that builds momentum for positive change?