Change Cycles Richard de Ferrars GP Faculty Frimley Park Hospital

Change Cycles How can we encourage patients to “buy-into” our ideas?

Change Cycles Can we do anything about “Not bovvered”?

Disclaimer – State the Obvious They way that people think and behave is totally unique Any model considering behaviour & changing it will be a simplification Does not mean that it is irrelevant!

Overview Scenario Scenario: You are in a consultation room with a patient who smokes 20 per day and has just been in hospital with their asthma In pairs, form a quick list of what you approaches you might take with them Summary from around the room - generate a list

Motivation to Change Dangerous assumptions: People want to change People ought to change The time is right NOW Tough approach works best I’m the expert, they must follow my advice The patient thinks & behaves in the same way that I do..... What would work for us must work for them.... This person is motivated by xxx

Sticks and Carrots Which works best? Which do we tend to use most? Are there stick people and carrot people?

Stick People Stick people worry about what might happen…. –best motivated by threat and worry –Leave things to the last minute –Tend to look at the negative aspects

Stick People Why do we select sticks? –We are a stick person? –We assume that the patient is a stick person? –We think it has most impact?

Carrot Man Carrot man looks at what could happen…. –Positive outlook –Looks for opportunity –Well-prepared

Carrot Man Why might we select carrots? –We are a carrot person? –We assume that the patient is a carrot person? –We think it has motivates best?

Sticks & Carrots Stick man worries about what might happen…. –best motivated by threat and worry –leaves things to the last minute –tends to look at the negative aspects Carrot man looks at what can happen…. –positive outlook –looks for opportunity –well-prepared Straw poll – stick or carrot?

Overview Scenario Scenario: You are in a consultation room with a patient who smokes 20 per day and has just been in hospital with their asthma In pairs, form a quick list of what you approaches you might take with them Have you selected sticks or carrots? Look at the list and assign “stick” or “carrot”

The Theoretical Bit Two theories/ models: Health Belief Model Rosenstock 1966 Transtheoretical Change Model Prochaska et al 1994

Health Belief Model Perceived susceptibility & seriousness of disease Perceived threat of disease Likelihood of change Cues to Action: education information Personal Factors: age, sex, ethnicity socio-economic factors knowledge What factors influence this perceived threat? What then is our role?

Transtheoretical Change Model Sounds very complex….. Is in fact very simple Five stages of change

Precontemplation Ignorance is bliss: Individual has not considered adopting the behaviour

Contemplation Considering adopting the behaviour but not taken any positive action

Preparation Individual has started to collect information and resources with a view to enacting the change

Action Individual has started to enact the behaviour but not yet continued over a long period

Maintenance The behaviour has been regularly enacted for more than 6 months

Change Cycles Precontemplation Contemplation Preparation Action Maintenance Our job is to energise this sequence Identify which stage the person is at Identify sticks/ carrots, support, services…. that could move them onto the next stage

Back to the list.... Go back to our list of interventions Which stage are they working on? Pick sticks & carrots that you could use at each stage Gaps? (eg no carrots at stage 1), think of how to fill the gaps 1.Precontemplation 2.Contemplation 3.Preparation 4.Action 5.Maintenance

Motivational Interviewing What is it? A client-centred, semi-directive method of engaging intrinsic motivation to change behaviour by developing discrepancy and exploring/ resolving ambivalence within the client. In my words – trying to make sure that it is the patient who will do the hard-work

Motivational Interviewing Grid for Assessing Motivation: AdvantagesDisadvantages No Change Change Scoring motivation: 1.Importance of making a change (score 1-10) 2.Confidence of making a change (score 1-10) In pairs: Try this out imaging you are an ES talking to their trainee about learning log entries….

Motivational Interviewing The Four A’s AskRaise issues in a non-confrontational way Assess motivation (1-10 importance & confidence) AdviseUse the grid so that patient gives themselves the advice Highlight contradictions “You say you smoke to help your nerves, but you also say that you worry about the effect of smoking on your health?” AssistElicit change talk Elicit self-motivating strategies “When I asked about motivation, why did you not score 0?” ArrangeFollow-up End positively – “Can always come back if needed” Roll with resistance – accept the patient’s outcome Not stick man’s approach?

How Can I Help My Patient? MI Tools Importance & Confidence (1-10 score) Change grid MI Fours A’s Ask & assess motivation Advise – change grid Assist – elicit change talk Arrange follow-up –End positively, roll with resistance Think carefully about sticks and carrots Think about influencing the “perceived threat” Think about the stage of the change cycle

The End