counselling in chronic disease management...
TRANSCRIPT
Counselling in Chronic Counselling in Chronic
DiseaseDisease MManagementanagement
11
(Motivational Interviewing)(Motivational Interviewing)
Adrian SchooAdrian Schoo
A/Prof of Physiotherapy, Rural Health School, La Trobe UniversitA/Prof of Physiotherapy, Rural Health School, La Trobe Universityy
Adjunct A/Prof, School of Medicine, Flinders UniversityAdjunct A/Prof, School of Medicine, Flinders University
What will be coveredWhat will be covered
�� Client focus in chronic disease managementClient focus in chronic disease management
�� Relevance of program adherenceRelevance of program adherence
�� Principles and characteristics of Motivational Principles and characteristics of Motivational
Interviewing (MI) or CounsellingInterviewing (MI) or Counselling
�� MI is solutionMI is solution--focused and effective. Effect focused and effective. Effect
diminishes over time and followdiminishes over time and follow--up is up is neededneeded
�� Importance of fostering ambivalence and Importance of fostering ambivalence and
using stepwise change talkusing stepwise change talk
�� Decisional balance list and SMART goal settingDecisional balance list and SMART goal setting
�� Goal ownership & the need to practice MIGoal ownership & the need to practice MI
FocusFocus (Doak, 1996)(Doak, 1996)
�� ProfessionalProfessional
•• Anatomy & physiologyAnatomy & physiology
•• Behaviours to maintain or Behaviours to maintain or
improve healthimprove health
•• Facts about the diseaseFacts about the disease
•• Skills to master healthSkills to master health--
related behavioursrelated behaviours
•• Frustration that patients do Frustration that patients do
not do what they shouldnot do what they should
•• Fear about malpracticeFear about malpractice
�� ClientClient
•• Why do I feel bad?Why do I feel bad?
•• Behaviours to solve disease Behaviours to solve disease
problemsproblems
•• Disease beliefsDisease beliefs
•• Skills to maintain a Skills to maintain a ““normalnormal””
lifelife
•• Frustration, fear, depression Frustration, fear, depression
about living with the diseaseabout living with the disease
•• Fear about the futureFear about the future
Generalisation ChronicGeneralisation Chronic--AcuteAcute(Adapted from Lawn & Schoo, 2010)(Adapted from Lawn & Schoo, 2010)
Acute conditionsAcute conditions
�� Relatively short episodeRelatively short episode
�� Cure to be expectedCure to be expected
�� Professional is the expertProfessional is the expert
�� Professional care influences Professional care influences health outcomeshealth outcomes
�� Health outcomes depend Health outcomes depend on shorton short--term service term service provisionprovision
�� Goals are short term Goals are short term
�� Program adherence is Program adherence is expected and less expected and less problematicproblematic
Chronic conditionsChronic conditions
�� Ongoing Ongoing
�� No cure to be expectedNo cure to be expected
�� Client is the expertClient is the expert
�� ClientsClients’’ decision making and decision making and selfself--management influence management influence health outcomeshealth outcomes
�� Health outcomes depend on Health outcomes depend on ongoingongoing support servicessupport services
�� SMART and shortSMART and short--term term goal goal setting setting to meet outcomes to meet outcomes over the longer termover the longer term
�� Program Program adherence is adherence is important important and can be and can be challengingchallenging
Relevant Adherence QuestionsRelevant Adherence Questions(Lorig, 1996)(Lorig, 1996)
�� Is adherence important for the problemIs adherence important for the problem
�� Is adherence believed to be importantIs adherence believed to be important
�� Are problem and strategy understoodAre problem and strategy understood
�� Are there the needed skills to manageAre there the needed skills to manage
�� Is there confidence in own abilityIs there confidence in own ability
�� Is there a willingness to adhereIs there a willingness to adhere
�� Is adherence punishing or rewardingIs adherence punishing or rewarding
�� Is required behaviour too complexIs required behaviour too complex
�� Is there the mental/physical capacityIs there the mental/physical capacity
Rogers appealed on internal Rogers appealed on internal
ability to control life by:ability to control life by:
�� Unblocking internal communicationUnblocking internal communication
�� Taking Taking responsibilityresponsibility for problemsfor problems
�� Recognising Recognising causalitycausality
�� Increasing mobilityIncreasing mobility
�� OwningOwning oneone’’s feelingss feelings
�� Living in Living in presentpresent momentmoment
�� Recognising and accepting negative feelingsRecognising and accepting negative feelings
�� Increased Increased independenceindependence from therapy from therapy
General counselling principlesGeneral counselling principles
1.1. Create ambienceCreate ambience
2.2. ListenListen
3.3. Ask openAsk open--ended questions (e.g., strategic Q)ended questions (e.g., strategic Q)
4.4. Detect opinions and valuesDetect opinions and values
5.5. Structure by reframing and deframingStructure by reframing and deframing
6.6. Ask the miracle questionAsk the miracle question
7.7. Identify underlying needsIdentify underlying needs
8.8. Provide opportunities to selfProvide opportunities to self--evaluateevaluate
9.9. Explore willingness to change picture albumExplore willingness to change picture album
10.10. Facilitate a responsible planFacilitate a responsible plan
Principles of motivational Principles of motivational
interviewinginterviewing (MI)(MI)
�� Express empathyExpress empathy
�� Develop discrepancyDevelop discrepancy
�� Avoid argumentationAvoid argumentation
�� Roll with resistanceRoll with resistance
�� Support selfSupport self--efficacyefficacy
Characteristics of MICharacteristics of MI
�� Client centeredClient centered
�� NonNon--judgmentaljudgmental
�� Expressing empathyExpressing empathy
�� Building trustBuilding trust
�� Being collaborativeBeing collaborative
�� Reflective listeningReflective listening
�� Increasing discrepancyIncreasing discrepancy
�� Exploring ambivalenceExploring ambivalence
�� Reducing resistanceReducing resistance
�� Increasing readinessIncreasing readiness
�� Eliciting change talkEliciting change talk
�� Increasing selfIncreasing self--efficacyefficacy
MI & Effect over timeMI & Effect over time
�� Immediate effectImmediate effect
�� Two treatments can be sufficientTwo treatments can be sufficient
�� Effect sizes diminish over time (from d = 0.77 Effect sizes diminish over time (from d = 0.77
at postat post--intervention to d = 0.30 at 6intervention to d = 0.30 at 6--12 12
months) (Hettema, Steele, & Miller, 2005)months) (Hettema, Steele, & Miller, 2005)
�� 66--monthly followmonthly follow--up sessions are likely to up sessions are likely to
increase effectiveness of MI in the increase effectiveness of MI in the
management of chronic diseasesmanagement of chronic diseases
�� Although interviewing requires a process, the Although interviewing requires a process, the approach is not rigid (training is available) approach is not rigid (training is available)
�� Skills are used to facilitate behavioural changeSkills are used to facilitate behavioural change
MI: Advantages & Barriers MI: Advantages & Barriers (Lawn & Schoo, 2010)(Lawn & Schoo, 2010)
�� Advantages:Advantages:�� Flexible and can be applied in many health settings, Flexible and can be applied in many health settings,
and incorporated in models of careand incorporated in models of care
�� Suits many clients with chronic diseaseSuits many clients with chronic disease
�� Can be used in lengthy as well as short consultationsCan be used in lengthy as well as short consultations
�� Well suited to support ongoing selfWell suited to support ongoing self--management and management and behavioural changebehavioural change
�� Barriers:Barriers:
�� Provides little formal structure and, as such, Provides little formal structure and, as such,
requires training of professionals that are not requires training of professionals that are not
experienced in counsellingexperienced in counselling
Theoretical models used in clientTheoretical models used in client--
centered counsellingcentered counselling
�� Health belief models Health belief models
�� Theory of critical conditions for changeTheory of critical conditions for change
�� Cognitive dissonance theoryCognitive dissonance theory
�� TransTrans--theoretical model of changetheoretical model of change
�� SelfSelf--perception theoryperception theory
�� Choice theoryChoice theory
�� SelfSelf--determination and the innate ability determination and the innate ability
to sort things outto sort things out
MI & selfMI & self--determination theorydetermination theory(Markland et al. 2005)(Markland et al. 2005)
�� Involvement leads to relatednessInvolvement leads to relatedness
�� Structure leads to competenceStructure leads to competence
�� Autonomy support leads to autonomyAutonomy support leads to autonomy
Involvement leads to relatednessInvolvement leads to relatedness
�� Express empathyExpress empathy
�� Explore clientExplore client’’s concernss concerns
�� Demonstrate understandingDemonstrate understanding
�� Avoid judgment or blameAvoid judgment or blame
Structure leads to competenceStructure leads to competence
�� Clear and neutral informationClear and neutral information
�� Agree on appropriate goalsAgree on appropriate goals
�� Provide positive feedbackProvide positive feedback
�� Support selfSupport self--efficacyefficacy
Autonomy support leads to Autonomy support leads to
autonomyautonomy
�� Avoid coercionAvoid coercion
�� Roll with resistanceRoll with resistance
�� Explore optionsExplore options
�� Encourage change talkEncourage change talk
�� Client decides what and how to changeClient decides what and how to change
belongingbelonging
HAVEHAVEWANTWANT
PW QW
freedomfreedom
funfun
powerpower
survivalsurvival
Sens Kn ValueSens Kn Value
Behavioural
system
W
TB
P
F
A
T
Using Choice
Theory and MI
How to motivate to become active and to stay active?
‘Inspiration drives action,more action …….. more inspiration’
Fostering ambivalence & Fostering ambivalence &
Stepwise change talkStepwise change talk
Ambivalence (promoted by empathy)
Desire → Ability → Reasons → Need → Commitment → Change
(direction is influenced by positively reinforcing client’s speech)
Useful tools for MIUseful tools for MI�� Decisional balance listDecisional balance list
�� Benefits/costs for making change or not making changeBenefits/costs for making change or not making change
�� Change plan worksheetChange plan worksheet
�� Identify desirable changes, reasons, steps, support of others, Identify desirable changes, reasons, steps, support of others,
realisation of success, enablers & barriers, and backrealisation of success, enablers & barriers, and back--up planup plan
�� Readiness rulerReadiness ruler
�� How ready are you to change (e.g., physical activity & diet)? How ready are you to change (e.g., physical activity & diet)?
What is needed to increase this?What is needed to increase this?
�� ExpectationExpectation
�� What is wanted from the intervention?What is wanted from the intervention?
�� Goal SettingGoal Setting
�� Importance of Importance of CClarity, larity, AAttainability and ttainability and PPayoffayoff
Decisional balance listDecisional balance list
Decision Changing Not changing
PAYOFF
Pros (Benefits)
……………….……………….……………….
……………….……………….……………….
Cons (Costs) ……………….……………….……………….
……………….……………….……………….
StrengthsStrengths--based approach based approach (McCashen 2005)(McCashen 2005)
Issue(s) FutureIssue(s) Future
Stories PictureStories Picture
………………. . ………………....
………………. . ………………....
………………. . ………………....
………………. . ………………....
………………. . ………………....
………………. . ………………....
………………. . ………………....
………………. . ………………....
Strengths Resources StepsStrengths Resources Steps
Explore Identify ConcreteExplore Identify Concrete
………………. . ……………….. .. ………………....
………………. . ……………….. .. ………………....
………………. . ……………….. .. ………………....
………………. . ……………….. .. ………………....
………………. . ……………….. .. ………………....
………………. . ……………….. .. ………………....
………………. . ……………….. .. ………………....
………………. . ……………….. .. ………………....
SMART goal settingSMART goal setting
�� Focus on process goals Focus on process goals ((not not
outcomeoutcome goals ) goals ) (Wilson & Brookfield, 2009)(Wilson & Brookfield, 2009)
�� ClientClient’’ss goals need to be: goals need to be:
�� SpecificSpecific
�� MeasurableMeasurable
�� AchievableAchievable
�� RealisticRealistic
�� TimelyTimely
Target practice enhancementTarget practice enhancement
�� Agree together (client and health professional) Agree together (client and health professional)
on one topic appropriate for the session (e.g., on one topic appropriate for the session (e.g.,
increasing level of physical activity)increasing level of physical activity)
�� Identify what client wants to know about topicIdentify what client wants to know about topic
�� Provide the requested informationProvide the requested information
�� Identify disease concerns, desired outcome, Identify disease concerns, desired outcome,
required steps to reach that outcome, and the required steps to reach that outcome, and the
barriers that may arisebarriers that may arise
�� Provide additional information if neededProvide additional information if needed
Continued Continued ……..
�� Agree on goals and action plan needed to Agree on goals and action plan needed to address clientsaddress clients’’ concernsconcerns
�� Provide clarification of goals and action plan, Provide clarification of goals and action plan, and utilize personal action plan worksheetand utilize personal action plan worksheet
�� Identify clientIdentify client’’s confidence in ability to carry out s confidence in ability to carry out agreed action plan on a scale from zero to 10.agreed action plan on a scale from zero to 10.�� In case confidence rates less than seven, identify In case confidence rates less than seven, identify
what needs to happen to make it higherwhat needs to happen to make it higher
�� Evaluate and refine the planEvaluate and refine the plan
�� Agree on one other relevant topic (e.g., diet)Agree on one other relevant topic (e.g., diet)
�� Etc.Etc.
Keeping a diaryKeeping a diary
�� Can assist in detecting adherenceCan assist in detecting adherence
�� Can assist in detecting levels of Can assist in detecting levels of
physical activityphysical activity
�� Can remind people to exerciseCan remind people to exercise
�� Can assist in establishing a routineCan assist in establishing a routine
In conclusion: What has workedIn conclusion: What has worked
�� Identify the individual drivers for participationIdentify the individual drivers for participation
�� Eliminate barriersEliminate barriers
�� Process goals work better than outcome goalsProcess goals work better than outcome goals
�� Programs requiring less intensity/structure work betterPrograms requiring less intensity/structure work better
�� Facilitate selfFacilitate self--management ownership. Let go of your management ownership. Let go of your
role as provider of solutions and doing things for clientsrole as provider of solutions and doing things for clients
�� Use strategies such as motivational counselling, followUse strategies such as motivational counselling, follow--
up telephone calls, diary up telephone calls, diary
�� Whatever the program is, it needs to be relevant to the Whatever the program is, it needs to be relevant to the
participant!!!participant!!!
ReferencesReferences�� Brunette, M., & Drake, R. E. (2007). Motivational counseling. Brunette, M., & Drake, R. E. (2007). Motivational counseling. Integrated Integrated
dual disorders treatment implementation resource kit dual disorders treatment implementation resource kit download.ncadi.samhsa.gov/ken/pdf/toolkits/cooccurring/DDWorkbdownload.ncadi.samhsa.gov/ken/pdf/toolkits/cooccurring/DDWorkbookAJ1_04.pdf.ookAJ1_04.pdf.
�� Cairney, J., Veldhuizen, S., Wade, T. J., Kurdyak, P., & StreineCairney, J., Veldhuizen, S., Wade, T. J., Kurdyak, P., & Streiner, D. L. r, D. L. (2007) Evaluation of 2 measures of psychological distress as scr(2007) Evaluation of 2 measures of psychological distress as screeners eeners for depression in the general population. for depression in the general population. Can J Psychiatry, 52Can J Psychiatry, 52(2), 111(2), 111--120. 120.
�� Glasser, W. (2000) Glasser, W. (2000) Counseling with choice theoryCounseling with choice theory. New York: . New York: HarperCollins.HarperCollins.
�� Hardcastle, S., Taylor, A., Bailey, M., & Castle, R. (2007) A raHardcastle, S., Taylor, A., Bailey, M., & Castle, R. (2007) A randomised ndomised controlled trial on the effectiveness of a primary health care bcontrolled trial on the effectiveness of a primary health care based ased counselling intervention on physical activity, diet and CHD riskcounselling intervention on physical activity, diet and CHD risk factors. factors. Patient Educ Couns, [Epub]Patient Educ Couns, [Epub](Nov 6).(Nov 6).
�� Hettema, J., Steele, J., & Miller, W. (2005) Hettema, J., Steele, J., & Miller, W. (2005) A metaA meta--analysis of research analysis of research on motivational interviewing treatment effectiveness. on motivational interviewing treatment effectiveness. Annual Review Annual Review of Clinical Psychology, 1of Clinical Psychology, 1..
� Jordan, J.E., & Osborne, R.H. (2007) Chronic disease selfChronic disease self--management management education programs: challenges ahead. education programs: challenges ahead. MJA 5;186(2):84MJA 5;186(2):84--7.7.
�� Lawn, S., & Schoo, A.M. (2010) Lawn, S., & Schoo, A.M. (2010) Supporting SelfSupporting Self--Management of Management of Chronic Health Conditions: Common Approaches. Chronic Health Conditions: Common Approaches. Patient Education Patient Education and Counseling. 2010;80(2):205and Counseling. 2010;80(2):205--211. 211.
�� Lorig, K. (1996) Lorig, K. (1996) Patient education: A practical approach. Patient education: A practical approach. Thousand Thousand Oaks: Sage Publications.Oaks: Sage Publications.
�� Markland, D., Ryan, R. M., Tobin, V. J., & Rollnick, S. (2005) MMarkland, D., Ryan, R. M., Tobin, V. J., & Rollnick, S. (2005) Motivational otivational interviewing and selfinterviewing and self--determination theory. determination theory. Journal of Social and Journal of Social and Clinical Psychology, 24Clinical Psychology, 24(6), 811(6), 811--831. Miller, W., & Rollnick, S. (2002). 831. Miller, W., & Rollnick, S. (2002). Principles of motivational interviewing: Preparing people for chPrinciples of motivational interviewing: Preparing people for changeange(2nd ed.). New York: Guilford Press.(2nd ed.). New York: Guilford Press.
�� McCashen, W. (2005) McCashen, W. (2005) The strengths approach: A strengthsThe strengths approach: A strengths--based based resource for sharing power and creating changeresource for sharing power and creating change. Bendigo: St Luke. Bendigo: St Luke’’s s Innovative Resources.Innovative Resources.
�� Morris M, Schoo AMM. Optimizing Exercise and Physical Activity iMorris M, Schoo AMM. Optimizing Exercise and Physical Activity in n Older People. Oxford, UK: Elsevier Science 2004 Older People. Oxford, UK: Elsevier Science 2004
�� Rosinin, P., Rees, M. E., Stott, N. C. H., Rollnick, S. R. (1999Rosinin, P., Rees, M. E., Stott, N. C. H., Rollnick, S. R. (1999) Can nurse ) Can nurse learn to let go? Issues arising from an intervention designed tolearn to let go? Issues arising from an intervention designed toimprove patientsimprove patients’’ involvement in their own care. involvement in their own care. Journal of Journal of Advanced Nursing,Advanced Nursing, 29(6), 149229(6), 1492--1499.1499.
�� Schoo, A.M.M. (2008) Motivational interviewing in the preventionSchoo, A.M.M. (2008) Motivational interviewing in the prevention and and management of chronic disease: Improving physical activity and management of chronic disease: Improving physical activity and exercise in line with choice theory. exercise in line with choice theory. The International Journal of Reality The International Journal of Reality Therapy, Vol 27, No 2 (Therapy, Vol 27, No 2 (www.choixdecarriere.com/pdf/5671/28.pdfwww.choixdecarriere.com/pdf/5671/28.pdf).).
�� Schoo, A.M.M., Morris, M.E., & Bui, Q.M. (2005) Predictors of hoSchoo, A.M.M., Morris, M.E., & Bui, Q.M. (2005) Predictors of home me exercise adherence in older people with osteoarthritis. exercise adherence in older people with osteoarthritis. Physiotherapy CanadaPhysiotherapy Canada, , 57(3):17957(3):179--187187..
�� Thoesen Coleman, M., & Newton, K. S. (2005) Supporting selfThoesen Coleman, M., & Newton, K. S. (2005) Supporting self--management in patients with chronic illness. American Family management in patients with chronic illness. American Family Physician, 72(8), 1503Physician, 72(8), 1503--1510. 1510.
�� Walker, D., & Sorkin, S. (2007) Walker, D., & Sorkin, S. (2007) AA--ha performance: Building and ha performance: Building and managing a selfmanaging a self--motivated workforcemotivated workforce. Hoboken, New Jersey: John . Hoboken, New Jersey: John Wiley & Sons.Wiley & Sons.
�� Wilson, K., & Brookfield, D. (2009) Effect of goal setting on Wilson, K., & Brookfield, D. (2009) Effect of goal setting on motivation and adherence in a sixmotivation and adherence in a six--week exercise program. week exercise program. IJSEP, IJSEP, 6, 896, 89--100.100.
�� http://www.groups.psychology.org.au/chphttp://www.groups.psychology.org.au/chp
�� http://www.health.vic.gov.au/communityhealth/downloads/fact_http://www.health.vic.gov.au/communityhealth/downloads/fact_
sheet5.pdfsheet5.pdf
�� http://patienteducation.stanford.edu/programs/cdsmp.htmlhttp://patienteducation.stanford.edu/programs/cdsmp.html
�� http://som.flinders.edu.au/FUSA/CCTU/self_management.htmhttp://som.flinders.edu.au/FUSA/CCTU/self_management.htm
�� http://userpage.fuhttp://userpage.fu--berlin.de/~health/hapa.htm berlin.de/~health/hapa.htm
�� http://www.motivationalinterview.orghttp://www.motivationalinterview.org
�� http://www.peersforprogress.org/http://www.peersforprogress.org/
Counselling in Chronic Counselling in Chronic
DiseaseDisease MManagementanagement
22
(Motivational Interviewing)(Motivational Interviewing)
Adrian SchooAdrian Schoo
A/Prof of Physiotherapy, Rural Health School, La Trobe UniversitA/Prof of Physiotherapy, Rural Health School, La Trobe Universityy
Adjunct A/Prof, School of Medicine, Flinders UniversityAdjunct A/Prof, School of Medicine, Flinders University
Time to Practice: Where to Time to Practice: Where to
start and how to finish?start and how to finish?
�� To do:To do:
�� OpenOpen--ended Qsended Qs
�� What bars you from What bars you from ……? ?
Have ever thought ofHave ever thought of……??
�� Explore clientExplore client’’s values, s values,
goals etc.goals etc.
�� Balance pros & consBalance pros & cons
�� Ask what is more Ask what is more
important, and how they important, and how they
think they can get where think they can get where
they want to bethey want to be
�� Observe cooperation Observe cooperation
�� Not to do:Not to do:
�� Closed QsClosed Qs
�� Question Question ‘‘whywhy’’ (it causes (it causes
defence of behaviour)defence of behaviour)
�� Judging and setting your Judging and setting your
own goalsown goals
�� Telling what is importantTelling what is important
�� Telling what to do and Telling what to do and
how to get therehow to get there
�� Outcome focused, being Outcome focused, being
absorbed in questions, absorbed in questions,
not observing resistancenot observing resistance
Application Application
of MI: of MI:
A caseA case
scenarioscenario
PracticalPractical
Sample Sample
questionsquestions
&&
ScenarioScenario
that needs that needs
SMART goal SMART goal
settingsetting
What can go wrong and why?What can go wrong and why?
�� Poor SMART goal setting, no backup planPoor SMART goal setting, no backup plan
�� The counsellor taking control and The counsellor taking control and
denying the opportunity for the client to denying the opportunity for the client to
have ownership of the processhave ownership of the process
�� Health professionals are trained to answer Health professionals are trained to answer
questions and to come up with solutionsquestions and to come up with solutions
�� This is one of the reasons that intervention This is one of the reasons that intervention
programs that use health professionals programs that use health professionals
with short training in counselling can fail with short training in counselling can fail (Rosinin et al. 1999)(Rosinin et al. 1999)
PracticalPractical
�� Scenario 1:Scenario 1:�� Primary prevention setting Primary prevention setting
(lifestyle)(lifestyle)
�� Scenario 2:Scenario 2:�� Secondary prevention setting Secondary prevention setting
(lowering specific risk factors)(lowering specific risk factors)
�� Scenario 3:Scenario 3:�� Tertiary prevention (diseaseTertiary prevention (disease--
specific)specific)
(Teams of 3(Teams of 3--6)6)
�� Client / actorClient / actor
�� Counsellor(s)Counsellor(s)
�� Observer(s)Observer(s)
PracticalPractical
�� Keep asking openKeep asking open--ended ended questions and find out:questions and find out:�� What the person likesWhat the person likes
�� LongLong--term vision term vision
�� Lifestyle behavioursLifestyle behaviours
�� How behaviours assist in getting How behaviours assist in getting what is needed in longwhat is needed in long--term term
�� What bars them from achieving What bars them from achieving what is desired? What will help?what is desired? What will help?
�� Underlying values. Not taking Underlying values. Not taking responsibility for own behaviour responsibility for own behaviour (e.g., blaming)(e.g., blaming)
(Teams of 3(Teams of 3--6)6)
�� One client or One client or patient (actor)patient (actor)
�� Two can help Two can help each other to ask each other to ask questionsquestions
�� Remaining Remaining members of the members of the team observe team observe (Notice when (Notice when there is energy, there is energy, when it clicks)when it clicks)
Evaluate practical 1Evaluate practical 1
�� What went well? What went well? Why?Why?
�� When did you feel When did you feel energy/cooperationenergy/cooperation
�� Where could you Where could you improve?improve?
�� What did not go so What did not go so well? Why?well? Why?
�� When did you feel When did you feel resistance? resistance?
�� How could you How could you improve next time?improve next time?
Thank youThank you