Advanced HCA Unit 4

RECAP

Reflective Accounts

Any issues to discuss

Communication

© Annie Barr 2023

HEALTH COACHING BEHAVIOURAL CHANGE: MOTIVATIONAL INTERVIEWING

Motivational interviewing

© Annie Barr

Five principles of motivational interviewing

 Express empathy through reflective listening

 Develop discrepancy between clients' goals or values and their current behaviour

 Avoid argument and direct confrontation

 Adjust to client resistance rather than opposing it directly

 Support self-efficacy and optimism

© Annie Barr

 Motivational interviewing (MI) is a process where medical professionals work together with their patients for a certain therapeutic outcome. A variety of skills and tools are utilized based on the stage of change the patient is at, working with the individual's internal motivations for behavioral change.

 Its ultimate goal is to solve a healthcare-related problem through patient introspection and empowerment. It combines technical aspects, such as open-ended questions and empathy, with a view toward a patient-centered approach.

 This activity discusses the different skills required for the successful utilization of MI on patient behavior as well as the current theories discussing how MI works to enact change.

© Annie Barr 2023

 MI uses a guiding style to engage clients, clarify their strengths and aspirations, evoke their own motivations for change and promote autonomy in decision making (Rollnick et al 2008).

 MI is based on these assumptions:

• how we speak to people is likely to be just as important as what we say

• being listened to and understood is an important part of the process of change

• the person who has the problem is the person who has the answer to solving it

• people only change their behaviour when they feel ready - not when they are told to do so

• the solutions people find for themselves are the most enduring and effective.

 The four general principles of motivational interviewing:

• R - resist the urge to change the individual’s course of action through didactic means

• U - understand it’s the individual’s reasons for change, not those of the practitioner, that will elicit a change in behaviour

• L - listening is important; the solutions lie within the individual, not the practitioner

• E - empower the individual to understand that they have the ability

What makes MI different from other, confrontational approaches?

 MI does differ substantially from more aggressive styles of confrontation. It is not:

• arguing with the client who has a problem and needs to change

• offering direct advice or prescribing solutions to the problem without the person’s permission or without actively encouraging the person to make their own choices

• using an authoritative/expert stance that leaves the client in a passive role

• where the health care professional does most of the talking, or only gives information

• imposing a diagnostic label

• behaving in a coercive manner.

STAGES OF CHANGE MODEL

 You may need to help your client explore the benefits of making a change and find ways around the potential barriers they may face. To help clients explore the importance of a specific behaviour change and increase their confidence to achieve their goal it helps to:

• start where your client is

• try to see the situation from their point of view

• if they want to change, encourage a realistic first step

• build of their existing strengths and positive past experiences

• use small measurements to assess and track their progress

• people are more likely to change when they for example, when they can see the benefit of changing

• if a person is not ready for a change for example, you should respect their decision

• if a person is unsure about making a change, you could ask them for example: what are the pros and cons of making the change?

• it helps to summarise and consolidate what you have discussed, so you could ask for example: who are you going to ask to support you?

• relapse prevention: You need to explore the potential of relapse and how they could prevent this from happening. You could ask for example: what makes this a good time to change?

© Annie Barr

The Readiness to change ruler

 While readiness to change can be evaluated using the Stages of Change Model, a simpler and quicker way is to use a Readiness to change ruler. This strategy asks clients to vocalise how ready they are to change using a scale of one to ten, where one = definitely not ready to change, and 10 = definitely ready to change.

 This allows you to immediately know your client’s level of motivation. Depending on where they are, the subsequent conversation will take different directions.

 Why not try it on yourself with the change you would like to make?

 Try asking your client how confident they feel to attempt a recommended change on a scale of 110. Then ask how them how motivated they feel to make the change on a scale of 1 -10. This ruler can be used to encourage clients to talk about how they have changed, what they need to do to change further, and how they feel about changing.

EXAMPLE

HCA talking about dieting

HCA: On a scale of one to ten, where one is definitely not ready to change and ten is definitely ready to change, what number best reflects how ready you are right now to diet and exercise more?

Client: Seven

HCA: And where were you six months ago?

Client: Three

HCA: So it sounds like you went from not being ready to change to thinking about changing. How did you go from a 'three' six months ago to a 'seven' now?

Client: I enrolled in a group slimming programme and this has helped to motivate me.

HCA: What would it take for you to move to an eight on the scale?

Client: Maybe I could get a friend to come with me, that would really help me to go every week and I'd have someone to chat to during the week.

Questions to elicit/evoke change talk

There are many ways to ask questions that will get your client to think about their behaviour.

 Here are just a few examples:

•  “What would be the good things about changing your [problem]?”

• “What would your life be like three years from now if you changed your [problem]?”

• “Why do you think others are concerned about your [problem

Questions to ask if your client is having difficulty changing

As we have discovered, change is hard and there are times when your patient will struggle. You need to focus on being supportive.

 These types of questions may help:

• “How can I help you get past some of the difficulties you are experiencing?”

• “If you did decide to change, what would you have to do to make this happen?”

Questions where your client has little desire for change

 There will be occasions when, despite your best efforts, you can see your client just does not 'get' that they need to change. In this situation you could then get them to describe in their own words what would be the extreme consequences of continuing on this path, and then what would be the consequences if they decided to change.

 Examples of the kind of questions you could use:

• “Suppose you don’t change, what is the worst thing that might happen?”

• “What is the best thing you could imagine that could result from changing?”

 Another technique would be to ask your client to compare their current situation and what it would be like to not have the problem in the future.

 These types of questions may help:

•

“If you make changes, how would your life be different from what it is today?”

• “How would you like things to turn out for you in two years?”

© Annie Barr 2023

Exploring importance and confidence

 Gauging how important a patient considers change and how confident they are about that change, are vital to change talk. These two ratings help us to understand how our patient's feel about the change and to what extent they feel it is possible.

 You can continually check these in your conversation with your clients (although don't overdo it) Importance and confidence ratings can be used to get patients to talk about what they would need to do to change. You can use their scores to explore their behaviour.

 Examples of how you can explore importance/confidence ratings:

•

© Annie Barr

“Why did you select a score of [insert #] on the importance/confidence scale rather than [lower #]?”

© Annie Barr

© Annie Barr

The real challenge is to recognise whether the person is ready to make a change in the first place and to ensure they are making the decisions for themselves. We are so used to telling people what to do that often we don’t recognise that it might be the patient’s own fault when the change process does not work well.  Some of the techniques in this resource will help you to improve your communication skills and your ability to see where you client is on their change journey.

 Remember that you are not:

• arguing that a person has a problem and needs to change

• offering advice without a client’s permission

• doing most of talking

• diagnosing a person’s problem

• responsible for making that person change.

© Annie Barr

If they are not ready to change, leave the door open and part on good terms.

 The model shows that before any change can take place, a person needs to believe there’s an advantage to changing and must be willing to put an effort into making this happen by deciding when, what and how to do it.

 Assessing your client's readiness to change is a critical aspect of MI. Motivation is not static and can change rapidly from day to day. If you can understand where your client is in terms of their readiness to change, you will be better prepared to recognise and deal with their motivation to change.

© Annie Barr 2023

Motivational Interviewing (MI) is a conversational style that facilitates collaboration between the healthcare provider and their patients. Its ultimate goal is to solve a healthcarerelated problem through patient introspection and empowerment. It combines technical aspects, such as openended questions and empathy, with a view toward a patient-centered approach

© Annie Barr 2023



STAGES

Precontemplation: The patient is not interested in changing their behavior and may have subjective justification as to why they shouldn't change

 Contemplation: The patient is considering change but may still cling to fears and reluctancy to start

 Preparation: The patient is actively preparing to change their behavior, potentially by considering tools and strategies to utilize, though it may require assistance with planning

 Action: The patient is working through their plan and using their tools to ensure success

 Maintenance: The patient has changed their behavior and is working to maintain the changes and not slip back into previous behaviors.

© Annie Barr