making every contact count motivational interviewing and
TRANSCRIPT
Making Every Contact Count Motivational Interviewing and
Behavioural change On-line training session (2.5 hours)
Clare Hodsdon – Senior Supportive Self-care Trainer Oxfordshire Clinical Commissioning Group | [email protected]
Recommendations
Explaining the bar
Mute on / off
Camera on /off
Click on the 3 dots if no ‘hand’
‘Conversation box’ for your questions
Share a document
• Recap what is Making Every Contact Count - key principles
• Discuss: What is Personalised Care
• Be introduced to Motivational Interviewing techniques
• BREAK
• Consider Behavioural change and the barriers to change
• Practical: Build your confidence and competence in having healthy lifestyles conversations
• If time, quiz on local health data
Aim of today’s session
BREAK
Group agreement • Confidentiality, anonymous scenarios etc.
• Raise a hand
• What’s said in this room stays in the room
• Respect others point of view
• Stay muted unless discussing/questioning/answering
• Keep camera’s on (unless you have informed trainer of broadband issues)
Lets introduce ourselves!
• Your name
• When did you last have a conversation about someone’s healthy lifestyle choice / health behaviour?
Pre Training
On a scale of 1-10, how important do you feel is it to have conversations about someone’s lifestyle behaviour?
Not important
Very important
On a scale of 1-10, how confident do you feel about having these conversations?
Not confident
Very confident
Origins of MECC, MI and Personalised Care
Due to the growing demands on health and social care…
Something has had to change…
Long term conditions in UK
15.4 million adults in UK = 1 or more LTC (30%)
• 50% of all GP appointments
• 64% of all outpatient appointments
• >70% of all inpatient bed days
Treatment and care = 70% total Health and Social care expenditure (on 30% of UK pop.)
https://www.kingsfund.org.uk/projects/time-think-differently/trends-disease-and-disability-long-term-conditions-multi-morbidity
What determines health and life expectancy?
Social
Circumstances 15%
Healthcare 10%
Environmental Hazards 5%
Genes 30%
Behaviour 40%
JSNA Oxon 2020: Death under 75yrs = 50%
were preventable
How were patients helped to accept huge life changing news and make decisions?
Consider traditionally…
Informed of a life long illness and advised on their future care and medication
Implications:
Accept medication for rest of life, need to understand new medications /treatment programme. Possible personal implications affecting relationships. Need to change lifestyle eg. lose weight or address an addiction
National GP Patient survey:
• Many patients were unsure and did not fully understand their conditions, wanted more information
• They did not feel in control, not listened to – which has an impact on mental health
• Not fully understanding medication, not taking meds. correctly – less effective – Waste (70% of meds)
• Not confident to make decisions without healthcare professional’s input – more appointment time needed
The build up to personalised care
A Review by Professor Sir Michael Marmot on how to reduce Health inequalities
Fair Society Healthy Lives (2010) 6 recommendations made on health inequalities “Strengthen the role and impact of ill-health prevention.”
Offers excellent insight into the background to health inequalities Gives effective evidence based strategies for reducing health inequalities in England
Commitment to making
personalised care a part of business as usual for the
health system
Roll out a comprehensive model of personalised care to
2.5 million people by 2023/24 (Double that by 2028/29)
In 2019: The NHS long-term plan calls for…
…a ‘fundamental shift’ in the way NHS works alongside patients and individuals…
In 2019: The NHS long-term plan calls for…
…a commitment to increasing support for people to manage their own health…
…training staff to be able to have conversations that help people make the
decisions that are right for them…
Universal Personalised Care (2019) Sets out how the comprehensive model of personalised care will be put into practice
6 Components of personalised care: • Shared decision making • Personalised Care and
Support Planning • Enabling choice • Social prescribing • Supported self-management • Personal health budgets
1 People are central in developing and agreeing their personalised care and support plan including deciding who is involved in the process 2 People have proactive, personalised conversations which focus on what matters to them, paying attention to their needs and wider health and wellbeing
Personalised Care In practices: Personalised Care and Support Planning / Year of care model
5 key criteria:
3 People agree the health and wellbeing outcomes they want to achieve, in partnership with the relevant professionals 4 Each person has a sharable, personalised care and support plan which records what matters to them, their outcomes and how they will be achieved 5 People are able to formally and informally review their personalised care and support plan.
5 key criteria contd:
Excerpt from: General Practice Forward View
NHS E commits to extra 2.4 million a year to support general practices by 2020/21
Quote ..”Patients want the knowledge, skills and
confidence to take more responsibility…”
Origins of: Personalised Care Personalised Care and Support Planning
• When patients understand more about their health and their condition, they are able to self-manage better which leads to improved health outcomes
• Encouraging and supporting behaviour change is now the nationally recognised approach to modern healthcare
Personalised Care and Support Planning process
Recording the agreed
& shared care plan
Information gathering
The conversation
Information sharing
Preparation
Results/agenda setting prompts
sent to patient > 1 week before
conversation
Conversation
A meeting of equals and experts
Prepared practitioner and patient:
• Review how things are going
• Consider what's important
• Share ideas
• Discuss options
• Develop a care plan
Disease surveillance
Tests and checks
performed where needed
© Year of Care Partnerships – April 2017
The ‘conversation’ Motivational Interviewing techniques and understanding of Behavioural Change
Meeting of equals and experts
Prepared practitioner and patient:
• Review how things are going • Consider what is important • Share ideas • Discuss options • Develop a care plan
• Good listening • Open Discovery Questions • Active Listening • Reflection • Summarising • Empathy
Vital consultation ‘conversation’ skills:
Recap: What is Personalised care?
In a nut shell: • The overarching term for patient-centred care, to include
the planning and delivery of all public facing care giving services.
• To offer time for a patient to be listened to, have an opportunity to ask questions, to reflect and plan in an equal manner with a clinician/practitioner on how they would like their care and treatment pathways to look like.
• To receive information and support when requested on how to make healthier lifestyle choices.
• Take control, self-manage own health conditions
Quick recap: MECC
MECC is …
• Evidenced - Behaviour change technique
• Holistic – looks at the whole person
• Brief, opportunistic, routine and everyday (less than 3 mins)
MECC is NOT…
• Telling people what to do
• Being an expert
• Adding to your already busy day
• Counselling or therapy
MECC is about using everyday conversations with people we meet to improve their health and wellbeing
Reference: National Making Every Contact Count Resources; Bicester Health New Town Cherwell District Council
5 lifestyle topics for MECC
Reference: National Making Every Contact Count Resources; Bicester Health New Town Cherwell District Council
1. Smoking
2. Physical activity
3. Weight and healthy eating
4. Alcohol
5. Mental health and wellbeing
National MECC programme supported by many health organisations:
• Public Health England
• NHS England and HEE
• Many localised MECC programmes across England
MECC programmes are
• For NHS
• And Non-NHS workforce
Website: www.makingeverycontactcount.co.uk
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MECC is a very brief intervention
Agree or Disagree?
People listen more to what they say than what I say
It is not possible to persuade people to change
their habits
References: Health Education England, Wessex - Healthy Conversations Training
Being given information alone does not make
people change People hold the key to
their own health “I am responsible for the changes people make or
don’t make”
Overall aim of MECC
• Planting a seed
• Supporting change
• Supporting others to identify their own solutions
• Listening and asking open questions
The 3 A’s: Ask, Assess, Act
1. Ask
Summarise, make goals, signpost Close the conversation
Their Capability, Opportunity, Motivation to change behaviour
Pick up on cues, ‘change talk’ and Ask Open Discovery Questions
2. Assess
3. Act
Ask,
Ask, Assess, Act
Listen out for some ‘Change talk’
You hear someone:
• Give a Reason to change
• A Desire to change • A Need to change
My cigarettes are getting so expensive
If I was happier with the way I looked I’d go out
more
If I was fitter I could do more with my grandchildren
Ask, Assess, Act
How could you respond?
Open Discovery Questions • ‘WHAT’ and ‘HOW’ • Try to avoid closed
questions and ‘why’ questions
You’ve started a conversation!
Oh I know, they are… how important is smoking to you
/ but, you sound a bit worried, what’s the biggest
worry about this?
Sounds like you’re ready for a change, how do you think you could feel more
energised?
what would make you feel happier? [An open question]
Ask, Assess, Act
What do you want to change?
How important is that to you?
How do you want to change that?
What are your priorities right now?
and that’s something you’d like to change?
Assess
Assess, The Stages of Change Model
Established change – Stable ‘safer’ lifestyle
Pre-contemplation – Not interested in changing
risky lifestyle
Adapted from Prochaska & DiClemente (1983)
At least 6 months to establish change
For smokers: Takes an average 7 attempts to give up for good
Capability
Motivation
Opportunity
Behaviour
Capability - Have the knowledge, skills & abilities to engage in a behaviour Psychological & physical
Motivation - Brain directs our decisions and behaviours Automatic & Reflective
COM-B: A simple model to understand Behaviour change (Reference: Michie et al. ,2011)
Opportunity - Outside factors which make the behaviour possible Physical & Social
For a person to change behaviour…
Ask, Assess, Act
How would you assess?
How do you think you’d go about making that
change? [An open question]
So you’ve been able to stop smoking for a couple of months
before … [Reflection]
It sounds like you are someone who’s determined
[Affirm their strength]
Are they Capable?
Do they have the Opportunity?
Are they Motivated?
You mentioned you’d like to be more active, what type of activity would you like to do?
[Reflection]
Ask, Assess, Act
What sort of role does smoking
/alcohol have in your life?
What do you think would help
you move on?
How important is smoking /
alcohol to you?
What would you like to happen before you could
make any change?
What else could you do? What else could you do?
Sounds like a lot going on…
Act
Ask, Assess, Act How could you act?
• Summarise – the
positive reflections
Well it sounds like you’ve learned a lot
about what worked in the past, and what
didn’t… How do you think you’ll go forward
this time?
Sounds like making a change is important
to you…
Sounds like a lot going on… What is the most
important thing for you at the mo.
Ask, Assess, Act How could you close the conversation?
• Next step • Leave the
‘door open’ • Set a goal?
Is there something else you’d like to talk about?
When do you think you’ll start …?
…and what else could you do?
[An open question]
There’s a free service that could support you with
that. Can I tell you more? Would you like more
information?
Ask, Assess, Act Closing the conversation?
OK, it’s not the right time at the moment but perhaps later down
the line, you could ask me …
Are you happy for me to send you the
information on the ….?
What will your next step look like?
• Give information • SIGNPOST or refer • NB. Ask permission first!
I know of a great support group, would
you like to know about them?
Motivational Interviewing (MI) Developed by William R Miller and Stephen Rollnick (1991)
Are you the cheerleader?
or The voice of
doom?
Or Do you feel like you’re carrying a ‘monkey on your back’
Motivational Interviewing definitions
Motivational Interviewing is about arranging conversations so that people talk themselves into change based on their own values and interests (Miller and Rollnick 2013)
Looking through:
‘strength focused glasses’
Guide, encourage, draw out, unravel, motivate, affirm, look
forward, evoke
3 C’s.. Cleverness, Complexity, Clutter
Calm, Curious, Compassionate
Motivational Interviewing R U L E
esisting the righting reflex
nderstand and explore
isten with empathy
mpower the patient
Motivational Interviewing (MI)
• Build a trusting relationship
• A person-centred form of guiding people
• Respectful, compassionate and evidence-based style of consultation – 30/70
• To help an individual change by exploring their beliefs, their values, their doubts and barriers and strengthening their inherent motivation to change
• Elicit self-change through negotiation
• Trick is to get the person to say it!
Motivational Interviewing (MI)
• First 2 minutes ‘sit on hands’
• Exchanging information – both assessing motivation and creating solutions
• Offers support and ‘space’ to reflect, think, create goals and actions to increase motivation and a capability to change
• Respects people’s autonomy, provoking their desire to change by taking a collaborative, not confrontational, approach
• Save ‘burn out’
Motivational Interviewing is NOT…
• A way of tricking people into doing what they do not want to do
• Cognitive Behavioural Therapy
• Client-centered counselling
• A theory or needing any assessment feedback
• Based on the Stages of change
• Or Easy!
It is a ‘tool’ to address a specific problem
Philosophy of Motivational Interviewing
?
Philosophy of Motivational Interviewing
• Observe and LISTEN – Express empathy
• Motivation has to come from the patient - based on their beliefs and values
• Allow the patients to articulate and resolve their insecurities, doubts and uncertainties
• Understand client resistance – roll with it!
• And…telling the patient what to do is not effective in encouraging change – avoid confrontation
Philosophy of Motivational Interviewing contd.
• Supporting self-efficacy and optimism (“You can do this, I believe in you”)
• Strategically steer the patient to realise potential and a decision to change
• Readiness to change is never fixed, readiness and motivation change fluctuates
• Patient and listener are in partnership, both experts, up to the listener to discover the clients wisdom
Break
Behavioural Change
Behavioural Change
• Important to support individuals throughout the process of change
• Over 50% dropout in the first 6 months
• Helpful for Health professionals to understand factors involved in behaviour change and maintenance
Approach Behaviour Change badly…
Push back from the patient
So… when supporting someone to change their behaviour
• Good to consider what is behind the behaviour
• To know that some behaviours are planned and deliberated on, while others are automatic and unconsidered
• Be able to relate behaviour to theory and models - help explain factors that influence
• Use a guide or a framework eg. RULE/OARS to support the delivery of your conversation / consultation
• What are the barriers…
So, what are the common barriers to change?
A vital concept - Perceived barriers
The challenge: Identify and help to change these perceived barriers
Some common barriers…
Attitude, FEAR, culture, preconceptions, historical experience, need to take
ownership, frustrations, beliefs, previous setbacks, feeling hopeless, not
engaging, commitment, time constraints, not right time,
education/knowledge, self-efficacy, head space, not motivated,
anxiety/depression, values, TRUST…
Models of Behavioural Change Help us interpret and organise information
1. Stages of change (Transtheoretical model)
2. Transactional Analysis 3. Bandura’s theory of Self Efficacy 4. Decisional balance
5. COM-B model
Transactional Analysis – The 3 Ego states
Reference: Berne E. 1964 – Transactional Analysis
Critical or nurturing parent
Adult – logical and rational
Adaptive or free child
Image: The Context of Things
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Self-efficacy: Bandura’s (1977) model of Self-efficacy
The degree of confidence/belief that an individual has in their ability to engage in a specific behaviour, in a particular setting with known outcomes. Self-efficacy is built through positive reinforcement and achieving bite size goals
Through the stages of change - self-efficacy increases and temptation to relapse decreases
Prochaska & DiClemente 1983
Decisional balance - Decision making Adding to the positive side of the scales
to tip the balance Central to Behavioural change process
‘Good’ behaviour
Less good behaviour
‘Change’ talk = Discuss both the positive and negative aspects of change
Coping with ambivalence (Resistance)
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There is internal conflict (mood swings)
Remain in balance = NO belief or value is stronger than another
Your golden ticket! Even for clients with low readiness - MI serves as a vital prelude to later therapeutic work.
• Accept, show you have heard what they said
• Ask and Assess, is there something ‘big’ going on?
• Not the right time “We can chat about this another time”
• Simply attacking or confronting directly does not always work - it may drive people deeper into a ‘shell’ or be highly defensive / confrontational
How do you approach ambivalence (Roll with Resistance)
Ambivalence: ‘Unravel’… To build motivation to change
• ‘Challenge’ underlying values and beliefs
• We know short term consequences seem more powerful… start ‘unravelling’…
• What’s the ‘internal voice’, their values and beliefs influence more than what others say
• Encourage possible solutions or alternative behaviour; what are their options
‘Unravel’… to build motivation to change
• Understand the positives v consequences of staying the same/no change
• Can you build self-belief, believe that they can change - see themselves as the ‘new’ person
• Start to see the opportunities open to them
• Listener increase their knowledge, capablity
Think of someone who has influenced you in your life
• What were their qualities?
• How did they behave?
• What were their skills?
• How did they make you feel?
‘Feeling the feelings’ Empathy - What is really going on…
“Empathy is the capacity to understand or feel what another person is experiencing from within the other person's frame of reference,
i.e. The capacity to place oneself in another's position”
Paul S. Bellet, Michael J. Maloney (1991).
We know…
• An individual’s motivation is influenced by the supportive style of the professional
• Ambivalence is normal and a natural stage in the process of change
• People often pass through several stages in the process of changing health behaviours (See Stages of change)
MI Conversation Skills - OARS
• Open discovery questions – To discover more about the person. ‘What’ and ‘How’ questions
• Affirmation – Confirm the great skills and characteristics someone has, will build self-efficacy and hope - belief they can change. You see their point of view
• Reflection – To repeat the speakers statements, using their words. This will guide the conversation, prompt more thought and show you are listening and interested.
• Summarise – Recall the issues succinctly, especially the positive reflections. This will help to clarify the issues and help prioritise.
Reference: Motivational Interviewing, Miller and Rollnick (1991)
OARS O = Open Discovery Questions (ODQs) Discover more - What and How!
• “What matters to you most?” • “What role does alcohol have in your life?” • “How do you feel about…?” • “What has brought you here today…?” • “Can you tell me about any concerns..” • “How confident do you feel about that?” • “Can you tell me what happened to trigger
the..?” • “What are the advantages of moving?” • “What else could you do?”
OARS A = Affirm You see their point of view, their skills and strengths, so they feel good about themselves
• “You’re a dignified man…” • “ That is really understandable…” • “You deserve to feel better than…” • “You handled yourself really well in that
situation” • “You are clearly very able to…” • “You really care a lot about your family” • “This is hard work for you” • “It took a lot of courage to come here today”
OARS R = Reflective listening (show your interest)
• “You sound really determined about that…” • “So this is something you would like to
change” • “It sounds like you would like to make some
changes” • “You’re wondering about…” • “I can see this motivates you…” • “I can hear in your voice that you’re …” • “ You’re fed up with…”
OARS S = Summary reflections Repeat the patients big issues
• “So you’ve said you are really worried about…” • “I think what you are saying is….” • “Let me see if I understand so far…” • “This is what I have picked up, tell me if I’m
incorrect…” • “I can see there are a lot of issues involved,
which one would you say is a priority?” • “When do you think that may happen?” • “If I understand you correctly, you’ve been
thinking of… but the downside would be..”
Case scenario time…
What’s their: • Age • Sex • Family • Home – live alone? • Work • Education
Reference: Bicester Healthy New Town Cherwell Distinct Council
• Income • Standard of
housing • Health conditions • Any other issues?
Wider determinants of health
Reference: The Dahlgren and Whitehead model of health determinants (1991)
Imagine a conversation? Hi there, how are you feeling?
OK, sounds like you’re not quite ready to change yet, that’s OK, let us know when you are and we can talk again.
How are you doing?
How are you coping?
You sound worried, what would you like to happen?
You look a little ‘off colour,’ how can we help you today?
It sounds like you have been thinking about this for a while, how would you like us to help you?
What do you think has caused this?
What sort of support do think you’d like?
You seem to be struggling a bit today, what would you like to happen?
You have mentioned your daughter a lot this week, are you worrying about something?
Oh dear, that does sound like a worry for you, what could we do to help you feel better?
It sounds like you have been thinking about this for a while, would you like me to tell you about some great support services?
Useful Tool: Scaling ‘importance’ or ‘confidence’
On a scale of one to ten:
1 - being not very important
10 - being very important
“How important is this for you?”
“How confident are you that you will achieve this?”
1 = not very important
10 = very important
No Change
Short term Long term Short term Long term
Good things (like) Less good things (don’t like)
Working towards increased physical activity
ST LT ST LT
Lose weight and so do more, feel more attractive, confident and buy nice clothes. Go swimming with kids
Feel good and proud of myself (Mental Health better)
Health - Greater risk of heart disease and Type 2 Diabetes. Feeling isolated.
Feel ugly, fat and unattractive, can’t buy nice clothes. Can’t run around with kids
Will have to buy some trainers. Stick to the routine and stay motivated
Good things Less good things
Don’t have to do anything, or decide where to go, what to wear or find the time
Making a Change
Finding the time to keep it up
Discuss?
save money
Post Training – please pop in the chat box
On a scale of 1-10, how important do you feel is it to have conversations about someone’s lifestyle behaviour?
Not important
Very important
On a scale of 1-10, how confident do you feel about having these conversations?
Not confident
Very confident
• Recap: What is Making Every Contact Count
• Considered some models and frameworks eg. 3 A’s, stages of change, OARS
• What is Personalised care
• Looked at good conversation skills, some MI techniques
• Discussed a case scenario
• Feel more confident and competent in having a conversation about someone’s healthy lifestyle choice and how you may guide a conversation around to changing a behaviour?
Summary of the session
Signposting to Oxfordshire services:
Live well: https://livewell.oxfordshire.gov.uk/ The Thames Valley MECC link: https://www.mecclink.co.uk/thames-valley/
The MECC app for
BOB Search for
‘Health Zone UK’ ‘signposting’
Local supportive services
MECC Training References
1. Healthy London Partnership, MECC Training
2. Health Education England Wessex, Healthy Conversations Training
3. Bicester Healthy New Town, Cherwell District Council, MECC Training
4. West Sussex County Council MECC Training
5. Public Health Promotion Resource Unit (PHPRU), Behaviour Change, Empowerment and Health Promotion Toolkit
6. West Midlands MECC Training (Training Tree)
7. Lincolnshire Country Council MECC Training
8. Shropshire Council, MECC Training
9. Kent, Surrey and Sussex MECC Training
10. Public Health England, National MECC Resources
11. Health Education England, MECC
12. Health Education North West, MECC
It’s not about the nail …
https://www.youtube.com/watch?time_continue=14&v=-4EDhdAHrOg
An example of having a conversation without MECC and then with MECC
Video: How to talk to your friends about mental health – MECC Produced by Healthy Cornwall
https://www.youtube.com/watch?v=AOucXkCAV7c&t=3s
An Effective Healthy Conversation - example
Video produced by Yorkshire and Humber Public Health Network https://www.youtube.com/watch?v=PtEXF4IRv-
M&list=PLNt6KNwtYISrUvBOsJBWIcs0DUvizhMZY&index=18&t=0s