Practitioner Development Programme

Skills Workshop 2

Welcome and Introductions

• 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

• Share your experiences from last workshop

• Skills, patients, systems

• Debrief

Aims Skills Workshop 2

During this workshop you will have the opportunity to explore the skills which support you to;

• 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

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Achieving improvement

by changing relationships

between people & health services

The nature of the interaction

created by the structures, processes and

behaviours that exist within the system

Patients, clients groups, service users, carers,

families and communitiesBoth the people who work in and deliver care services and

the wider system

Safe, effective, timely, person centred, equitable

and efficient

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The CCH Integrated Skills Model

E

©The Health Foundation

Agenda setting

Goal setting & Action Planning

Goal follow - up

Exploration

PlanningProblem solving

Health behaviour modeling

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Biological

Social / BehaviouralEmotions / Thoughts

Skills list

•Reflection/Empathy

•Explore agenda/priority

•Explore agenda: clarify boundaries

•Explore beliefs about self-management

•Explore importance 0-10

•Explore confidence 0-10

•Support autonomy & choice

•Double-sided reflection

•Explore ambivalence

•Invite goals

•Ask before advise

•Problem solving

•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

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Source: Prof Judy Hibbard, University of Oregon

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;

• 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?

• 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 & interventionsStage 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

• 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 importanceUsing 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 –

• 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• 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

• 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• 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

• 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

• 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• 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 upthemselves later in the same consultation or at a later date

Inviting goalsOnce you have explored importance and confidence support the patientto 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

• 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

• Consider the skills we have covered and decide what you would like to try

• Most useful to select an area for which you attach high importance and have low confidence

• 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;