Transcript Presentation title - Health Foundation

Practitioner Development
Programme
Skills Workshop 2
Welcome and Introductions
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Tutors
All in group
Name and area of work
House keeping;
-Manage self
- All teach all learn
-Toilets
-Fire alarm & exits
-Refreshments
-Mobile phones
Successes & Challenges
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Share your experiences from last workshop
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Skills, patients, systems
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Debrief
Aims Skills Workshop 2
During this workshop you will have the opportunity to explore the skills
which support you to;
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Understand the patient’s perspective (health beliefs and patient activation)
Explore patient importance
Explore patient confidence
Help patients at the beginning of the journey to move forward; exploring
ambivalence
Support the patient to move forward with goal setting & action planning
You will also have the opportunity to consider how your team and services
work and how these processes impact your ability to successfully support
patients to self manage and identify ideas you have to overcome barriers
Programme aim – review
Safe, effective, timely,
person centred, equitable
and efficient
The nature of the
interaction
created by the structures,
processes and
behaviours that exist within
the system
Achieving improvement
by changing relationships
between people & health services
Patients, clients groups,
service users, carers,
families and communities
Both the people who work in
and deliver care services and
the wider system
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The CCH Integrated Skills Model
Exploration
E
Agenda
setting
Goal
setting &
Action
Planning
Planning
Goal
follow
- up
Problem
solving
©The Health Foundation
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Health behaviour modeling
Biological
Emotions / Thoughts
Social / Behavioural
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Skills list
•Reflection/Empathy
•Support autonomy & choice
•Explore agenda/priority
•Double-sided reflection
•Explore agenda: clarify
boundaries
•Explore ambivalence
•Invite goals
•Explore beliefs about selfmanagement
•Ask before advise
•Explore importance 0-10
•Problem solving
•Explore confidence 0-10
•Action planning
•Effective Follow-up
Patient journey
Importance
Confidence
Problem
Solve
Beginning
Low
Low
Low
Finding a
way
Mod-high
Low
Low
Travelling
High
High for
some
Low
Staying on
track
High
High
High
Building activation
Source: Prof Judy Hibbard, University of Oregon
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How do I know where the patient is?
Explore patient levels of activation, confidence and problem
solving. Find out about their beliefs about self management.
Listen for ‘change talk’- phrases such as ‘I tried to…’, I
thought about..’ . Acknowledge and affirm.
Be enquiring and interested. Give good amounts of time for
response. Resist the urge to give information, justify or
problem solve;
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What has been working well for you?
What have you been doing that is contributing to your health?
What do you know about living with…?
What ideas/concerns/expectations do you have?
What are your thoughts about what you can do?
What’s the value in understanding
patient activation?
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Builds respect and rapport
Shared understanding of knowledge & information
Determines what are ‘realistic next steps’ for individuals to take
Maximises opportunity for best use of time
Matches intervention to patient need
Builds confidence
Builds problem solving skills
Builds activation
Reflections
• Many of the behaviours we are asking of people are only done by
those in the highest levels of activation
• When we focus on the more complex and difficult behaviours, we
discourage the least activated
• Starting with the behaviours more feasible for patients to take on,
increases the individual’s opportunity to experience success
• For all of us we have probably achieved the changes we find
relatively easy and we are left with those that (for whatever reason)
we find difficult, make us feel vulnerable or that we have little
confidence to achieve
Stage & interventions
Stage
Intervention
Beginning
Level 1
Pre-Contemplation
Explore health beliefs
Importance scaling
Explore ambivalence
Finding a way
Level 2
Contemplation
Supported small achievable goal setting to increase
confidence
[Explore ambivalence]
Travelling
Level 3
Action
Sign posting information, education & specialist services
Support to develop problem solving skills
Staying on track
Level 4
Maintenance
Support to increase problem solving skills
Assessing where the patient is on their journey–
Interactive exercise
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Lay tutor or actor give extracts of dialogue that patient may use in a
consultation group - feedback regarding where they think the patient is
on their journey of self management
Explore and discuss other phrases and terms that patients may use
Consider how these map to activation, the journey and the intervention
Next step - Exploring importance
For patients who are at the beginning of their journey it is
helpful to consider how important a health behaviour
change might be to them. You may pick up on a cue during
the conversation or you may explore their beliefs, thoughts
and ideas in a neutral and non judgemental way
• I am interested to know your thoughts about smoking?
• How do you feel about your weight?
After further dialogue move onto finding out how important
the health behaviour change is to them (not for them)
Exploring importance
Using Importance scaling
Needs to be linked to a verb (action) & have explanation of
anchors with neutral voice and body language
‘On a scale of 0-10 how important is it to you right now to
stop smoking with 0 being no importance at all and 10 being
the most important thing in your life?’
‘It sounds as though you are really fed up with your weight. I’d
like to understand how important you feel it is to you to lose
weight on a scale of 0 to 10, with 0 being no importance and 10
being the most important thing right now’
The value of scaling – benefits and
challenges –
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Whole group free think discussion
Draw a vertical line down middle of flip chart
One side record clinician perceived benefits of using scaling
Other side record clinician perceived challenges of using
scaling
• Repeat from the patient’s perspective
• Debrief
• Review the lists once you have completed the scaling
section to see how you now feel about the challenges
The value of scaling – benefits and
challenges; some examples from groups
•Clarification & confirmation
•Shared understanding
•Patient hears themselves say how
important it is to them
•Builds self reflection
•Creates structure to move forward
•Baseline
•Repeatable
•Transferable
•Builds problem solving skills
•I don’t like using scales
•They don’t work
•I might sound patronising
•I know what the patient is thinking
•They will sound repetitive
•Patient’s don’t like them
•It take too much time
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Scaling: How to progress – mid range
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The actual number is not important
How you respond to it is
Maintain equipoise (neutrality)
If response is low to mid range e.g. 4
Explore what makes it a 4 rather than a 3?
Progress to ‘What would it take / what would need to happen to move it to
a 5 or a 6 ? (avoid ‘why’)
Use your exploring skills to support patient to consider all contributing
factors (What else could you consider? What else?)
With all scaling never move more than one or two numbers up or down
Do not waste valuable time exploring what didn’t work before. We are all
too familiar with our failures
Use positive reinforcement and reflection to affirm importance however
resist temptation to use adjectives to praise high number as confidence
often low
How to progress – high range
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Number not important – maintain equipoise
8+ Use positive affirmation rather than adjective ‘so it’s really important to
you’ rather than ‘that’s fantastic/that’s really good’
Move on to confidence scaling
7+ - consider the context and the individual – you can either move straight
to confidence scaling or it may be worth investing some time in exploring
importance further
This approach will elicit the positive reasons the patient has to change
There is benefit and value to both parties hearing this information
Use valuable time proactively and move onto exploring confidence
Exploring confidence
There is huge value in separating importance and confidence.
Often importance is high, however confidence is low
Having this information provides a structure to move forward and
support people to identify and access the things they need to
improve their confidence
Family and friends may assume that patients to not want to change
and this may cause conflict.
Understanding and acknowledging that importance and confidence
are two separate factors allows clinicians, patients, family and
carers to understand how they can best offer helpful and proactive
self management support
Exploring confidence
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Use same the same techniques
Verb and anchors
Neutrality and equipoise
No adjectives
What makes it 3 rather than a 1 or 2
Explore all elements; what else?
What would help take it up to a 4 or 5
Initiates problem solving
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The areas that would help increase confidence will often reveal an
area for which the patient may want to explore goal setting &
action planning
How to progress – low range & zero
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Number not important – maintain equipoise
Neutral and non-judgemental
Remember your non verbal body language
Avoid adjective for number
Move to exploring ambivalence
• Don’t worry if it’s zero
Enhancing Importance & exploring ambivalence
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Acknowledge that ambivalence is a normal part of change
Ambivalence can occur at multiple stages of the journey
Motivation is particularly difficult after a period of illness, exacerbation or
negative life event/stress
Sensitive support to help your patient to explore and reflect on their
ambivalence will support their autonomy and help them move forward in
their contemplation of change
There are costs and benefits to all change
This decisional balance is what will progress or impede contemplation of
change
Resist the temptation to try to ‘persaude’ them or remind them of the health
benefits of change and the ‘dangers’ of staying the same
Exploring ambivalence
• Using the techniques of OEQ’s, reflection, summary reflection
and empathy
• Work with the patient to find out all their reasons, benefits and
thoughts about staying the same….
• Then repeat this process to find out all their reasons, potential
benefits and thoughts about staying the same
• It is important to remember to use the patient’s words and not
add any thoughts or judgements of your own
Double sided reflection
• The information that the patient shares is like two sides on a set of
weighing scales, the benefit and the cost of that change for that
individual
• Reflect these back to the patient using their words & phrases…on
the one hand...on the other hand…(resist the temptation to add any
additional benefits that you have thought of)
• Underpin with an empathic statement…I can see that is a real
dilemma for you…that must be really tough
• Leave a pause for contemplation
• Resist judgement or opinion and remember your non verbal body
language
Double sided reflection – Interactive exercise
• Draw a set of scales on flipchart
• On one side of the scales ask the group to list some of the reasons
people cite for continuing to smoke, keep exploring until you have
4 or 5 (with a patient you would continue to elicit all the reason) put
on one side
• On the other side list some of the potential benefits of giving up
smoking
• Ask someone to reflect this back to the group using the groups
language and phrases..’So on the one hand you really enjoy
smoking and .... And.... And...
• On the other hand giving up would mean that...... And.....And.....
• Underpin with an empathic statement
• Pause for contemplation
• Debrief
Reflections
• Letting the patient know you are trying to understand their dilemma
is very powerful
• Patients may expect us to try to persaude them to change, this can
results in a cycle of defensiveness
• Patients will only contemplate a behaviour change if it is important
to them in the context of their life and priorities
• This process allows the patient ‘space’ to consider and may take
time
• You may not experience immediate feedback unlike some of the
other skills
What to do if it’s zero
Support patient autonomy, acknowledge and respect their view.
Use neutral and non judgemental verbal and non verbal body language.
Offer future opportunity
• Reflect back to patient...’Thank you it’s sounds as though that’s
really not important to you or something you want to discuss at the
moment’
• ‘I respect that, let me know if you change your mind and you would
like us to explore it another time’
Patients who do not feel forced to explore an area often bring it up
themselves later in the same consultation or at a later date
Inviting goals
Once you have explored importance and confidence support the patient
to consider an area that they wish to work on and help them set a goal
and action plan around this. This is the first step in supporting them to
translate intention into action. Remember to support their autonomy
and choice and be mindful of their level of activation.
You can take a long term view. Your patient is living with a LTC and
you have time to support small incremental progress which will build
confidence and skills
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Is there an area that you would like to work on?
How might you go about that?
How important is it to you?
How confident do you feel ?
Examples of Activating interventions
•Confidence Ruler
•Decision aids
•Goal setting and action planning forms
•What do we need to change in the way we work that will
support collaborative agenda setting and how might we do this?
Experiential practice
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Consider the skills we have covered and decide what you would
like to try
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Most useful to select an area for which you attach high importance
and have low confidence
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Safe environment to try things in a different way and seeing what
happens
Action plan & next steps
The skill I am going to work on;
The patient focused activity I am going to work on;
The process I am going to work on;