Supporting our patients to become more activated and engaged 6 th December 2016

1. Supporting our patients to become more activated and engaged 6th December 2016

2. Welcome and setting the scene Alison Manson

3. “The definition of insanity is doing the same thing over and over again and expecting different results” Albert Einstein

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

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

7. Are we measuring what really matters? “People crave a life not a service” The care we provide is a means to this end

8. Outcomes for people not pathways

9. Another way to look at it

10. The ambition forfor Nottingham City Life Improver Score

11. There is something in human nature that resists being coerced and told what to do. Ironically, it is acknowledging the other’s right and freedom not to change that sometimes makes change possible. Rollnick S, Miller WR, Butler CC. Motivational interviewing in healthcare. Helping patients change behaviour. New York: Guilford Press (2008).

12. 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

13. It’s not WHAT we know it’s how we blend it all together

14. 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

16. 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 stated goals /values and behaviours

17. 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 and activates change

18. Before we start a word about Ambivalence Me ambivalent ? ….Well yes and no

19. So what do we mean by Ambivalence • Having mixed (or opposite) feelings thoughts about the same thing • Simultaneous conflicting feelings • Being in two minds about something • Need to change VERSUS the reality

20. Ambivalent?

21. 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

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

24. 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 -Autopilot or in the moment?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

25. 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….

26. Motivational Interviewing – a different approach Task led is what we will do – INPUTS Patient led - what are you trying to achieve – OUTCOMES Process led structured approach – you may already be doing this!

27. 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

28. 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

29. Health Related Behaviour Change • Increasing numbers of people living with long term conditions and what people can do to improve their health • No person is completely unmotivated • The way we talk to patients about their health can substantially influence their personal motivation for behaviour change and instil confidence…….

31. The process of change • People change behavior because they are: • Ready • Willing • Able • Change is not linear • Change is most persistent when it is internally motivated

32. Behaviour Change We can be STUCK for months or years

33. Realities of Change •Change does not occur overnight •Change is a gradual process withoccasional setbacks – not an outcome •Thinking and Doing components •Other positives/successes occur

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

35. Cycle of Change

36. Cycle of Change

37. 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

38. Mapping what we do at each stage

39. Features of Stages of Change Model • People can present at any stage • People progress through stages of change • Movement may be forward and/or backward • The model normalises relapse • – it is expected!

40. Techniques of MI  Rolling with Resistance - Avoid arguing • Open-ended Questions • Affirmations • Summarise • Develop Discrepancy • Support Self-Efficacy  Empathy

41. Empathy

42. Insert video Brené Brown on Empathy

43. ARGUMENT INCREASES RESISTANCE

44. AVOID ARGUMENT AT ALL COSTS • Arguments are counter-productive • MI is in itself challenging and confrontational in that it questions how much the patient wants to change • The goal of MI is to encourage the patient to hear themselves say WHY they want to change, not to keep repeating existing reasons for failing to change • If you don’t seem to be listening actively to the reasons why change for your client is problematic, they will work hard to convince you that these reasons are legitimate and that they are not being neglectful or difficult. This can consolidate their existing thinking and increase their resistance to change

45. ROLL WITH RESISTANCE • When encountering resistance to change, do not confront it directly • Reframe it and reflect it in a way that decreases resistance • Avoid arguing for change  Encountering resistance is a sign you should shift your approach

46. ROLL WITH RESISTANCE Dancing vs.Wrestling Guiding vs. Directing Tapping vs. Pulling Consulting vs. Instructing When you encounter resistance, step back, listen, and try to understand things from the patent’s perspective.

47. DEVELOP DISCREPANCY The patient needs to have goals to work towards and to realise that their current situation has consequences Goals should be generated by the patient and not imposed upon them (SMART goals?) Check on how realistic these goals are. Can the patient think what might prevent them from being achieved? Can they prioritise them into a hierarchy? Identify the difference between the current and ideal situation. Consider aids such as metaphors to explain the nature of change

48. 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?

49. CHANGE People say they want to change – yet continue with disruptive behaviour …. • “If you continue with x behaviours what might happen?” • “How does this …. fit with being well?” CHANGE EQUATION

50. The Spirit of MI • Collaboration versus Confrontation • Evocation versus Education • Autonomy versus Authority