"Educational Tools for Dealing with Trainees with Difficulties"




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The importance of ROLE MODELLING (14) in developing trouble free training

Role models have been described as "individuals admired for their ways of being and acting as professionals." The characteristics of role models can be divided into clinical competence, teaching skills and personal qualities. Learning from role models occurs through observation and reflection, and is a complex mix of conscious and unconscious activities. Remembering and understanding the power of the unconscious component is essential and depends on active reflection to convert an unconscious feeling into conscious thought that can be converted into action. Observed behaviours are also unconsciously incorporated into the belief patterns and behaviours of the student in a powerful way.

We now understand that there is a formal, an informal, and a hidden curriculum. Role models function in all three.

  • The formal curriculum is outlined in mission statements and course objectives, detailing what faculty members believe they are teaching. Role modelling certainly takes place here, and the conduct of medical teachers at this level can have a profound effect. Teachers who show passion and enthusiasm for medicine can be extremely effective; failing to do so is to miss a valuable opportunity.

  • The informal curriculum, which consists of unscripted, unplanned, and highly interpersonal forms of teaching and learning, is very powerful. All role models, from peers to senior doctors, function in the informal curriculum,and many of the corrosive effects of negative role modelling are experienced here.

  • Finally, a set of influences, which are largely hidden, function at the level of the organisational culture and structure of the institution. The influence of this hidden curriculum on role modelling can be profound, as many of the barriers to effective role modelling can be found here.

Key points


Role modelling is a powerful teaching tool for passing on the knowledge, skills, and values of the medical profession, but its net effect on the behaviour of students is often negative rather than positive

By analysing their own performance as role models, individuals can improve their personal performance

Strategies are available to help doctors become better role models:

  • Being aware of the impact of what we are modelling (be it positive or negative)

  • Protecting time to facilitate dialogue, reflection, and debriefing with students

  • Making a conscious effort to articulate what we are modelling, and to make the implicit explicit

The characteristics of role models have been well documented and can be divided into three categories:

Clinical competence encompasses knowledge and skills, communication with patients and staff, and sound clinical reasoning and decision making. All of these skills must be modelled as they lie at the heart of the practice of medicine.

Teaching skills are the tools required to transmit clinical competence. A student centred approach incorporating effective communication, feedback, and opportunities for reflection is essential to effective role modelling.

Personal qualities include attributes that promote healing, such as compassion, honesty, and integrity. Effective interpersonal relationships, enthusiasm for practice and teaching, and an uncompromising quest for excellence are equally important.





Strategies to improve role modelling

  • Be aware of being a role model and share that awareness with the learner

  • Demonstrate clinical competence

  • Protect time for teaching

  • Show a positive attitude for what you do Consciously modelling competence, positive attitudes, and enthusiasm for the practice of medicine can be transformative. However, we need to ensure that the behaviours being modelled are made explicit to the learner.

  • Implement a student centred approach to teaching

  • Facilitate reflection on clinical experiences and what has been modeled. Examine and explore work as we do it as "reflection in action." It is also helpful to discuss with students the impact of the encounter on the patient, the student, and oneself after it has occurred—"reflection on action." If we then relate this experience to future actions, we are engaged in "reflection for action."

  • Encourage dialogue with colleagues

  • Engage in pertinent staff development

  • Work to improve the institutional culture which encourages overwork, resulting in insufficient time for teaching a lack of institutional support for teaching and a culture that accepts inadequate patient care or poor relationships between members of the healthcare team. Methods for doing so depend on the local organisation and culture; they include raising awareness, pointing out deficiencies, reinforcing strengths, analysing the local environment, and proposing remedial action, which will often include staff development. The object is to create an environment that supports positive role modelling.

  • Whenever possible be explicit about what you are modeling



ROLE MODELLING TEMPLATE OF POSITIVE AND NEGATIVE INFLUENCES





MINUS


PLUS



P

L

U

S


- +

NEGATIVE ROLE MODELLING BUT IF EXPLORED OPENLY AND EXPLICITLY WITH THE TRAINEE CAN BECOME A POSITIVE EXPERIENCE


+ +


GOOD ROLE MODEL WITH POSITIVE INFLUENCE EITHER HIDDEN OR EXPLICIT



M

I

N

U

S


- -


NEGATIVE ROLE MODELLING WITH NEGATIVE INFLUENCE EITHER HIDDEN OR NOT DISCUSSED


+ -


GOOD ROLE MODEL BUT MAY HAVE DIFFERENT VALUES TO THE TRAINEE SO EXPLICIT DISCUSSION NEEDED TO AVOID NEGATIVE IMPACT

Logical levels are again useful when exploring what is going on in role modeling.

Environment – For example is where you are working light and comfortable or constrained by crowded space and interruptions.

Behaviour – The thing that is most easily observed by trainees is how we behave. Are you seen to be respectful or rude to colleagues?

Capability – Gives many useful lessons on how we actually do the day to day work.

Beliefs – Explore the why we do things and why they may differ from a different generation of learners. “You regularly criticize blogging and social network sites. You’re trainee is distressed because they are feeling isolated as the single trainee in the practice and afraid to use the social network sites that help them chat about the stress of the job.

Identity and values – You’ve stopped going for coffee and spend all your break time checking computer results and ensuring all your QOF work is picking up all available cash. This is giving a mixed message to the trainee who hears you say how much you value “good informal learning time together and patient continuity of care over financial reward”

Social construct theory and the importance of understanding self efficacy in trainees

"Learning would be exceedingly laborious, not to mention hazardous, if people had to rely solely on the effects of their own actions to inform them what to do. Fortunately, most human behavior is learned observationally through modeling: from observing others one forms an idea of how new behaviors are performed, and on later occasions this coded information serves as a guide for action."
-Albert Bandura (15)

What his social construct theory adds to other adult learning theories is a social element, arguing that people can learn new information and behaviors by watching other people. Known as observational learning (or modeling), this type of learning can be used to explain a wide variety of behaviours.

Observational Learning

In his "Bobo doll" studies, Bandura demonstrated that children learn and imitate behaviours they have observed in other people. This becomes particularly powerful when the behaviour is learnt from an adult and that although violent behaviour patterns were higher in boys if a female adult showed aggressive behaviour it had a significant negative effect on girls.

Bandura identified three basic models of observational learning:

  1. A live model, which involves an actual individual demonstrating or acting out a behaviour.

  2. A verbal instructional model, which involves descriptions and explanations of a behaviour.

  3. A symbolic model, which involves real or fictional characters displaying behaviours in books, films, television programs, or online media.

Intrinsic Reinforcement

Bandura noted that external, environmental reinforcement was not the only factor to influence learning and behavior. He described intrinsic reinforcement as a form of internal reward, such as pride, satisfaction, and a sense of accomplishment. This emphasis on internal thoughts and cognitions helps connect learning theories to cognitive developmental theories.

The Modeling Process

Not all observed behaviors are effectively learned. Factors involving both the model and the learner can play a role in whether social learning is successful. Certain requirements and steps must also be followed. The following steps are involved in the observational learning and modeling process:


Attention

In order to learn, you need to be paying attention. Anything that detracts your attention is going to have a negative effect on observational learning. If the model is interesting or there is a novel aspect to the situation, you are far more likely to dedicate your full attention to learning.

Retention
The ability to store information is also an important part of the learning process. Retention can be affected by a number of factors, but the ability to pull up information later and act on it is vital to observational learning.

Reproduction

Once you have paid attention to the model and retained the information, it is time to actually perform the behavior you observed. Further practice of the learned behaviour leads to improvement and skill advancement.

Motivation

Finally, in order for observational learning to be successful, you have to be motivated to imitate the behavior that has been modeled. Reinforcement and punishment play an important role in motivation. While experiencing these motivators can be highly effective, so can observing others experience some type of reinforcement or punishment. For example, if you see another student rewarded with extra credit for being to class on time, you might start to show up a few minutes early each day.

SELF EFFICACY

Self-efficacy is a person’s belief in his or her ability to succeed in a particular situation.

The Role of Self-Efficacy

Virtually all people can identify goals they want to accomplish, things they would like to change, and things they would like to achieve. However, most people also realize that putting these plans into action is not quite so simple. Bandura and others have found that an individual’s self-efficacy plays a major role in how goals, tasks, and challenges are approached.

People with a strong sense of self-efficacy:

  • View challenging problems as tasks to be mastered.

  • Develop deeper interest in the activities in which they participate.

  • Form a stronger sense of commitment to their interests and activities.

  • Recover quickly from setbacks and disappointments.

People with a weak sense of self-efficacy:

  • Avoid challenging tasks.

  • Believe that difficult tasks and situations are beyond their capabilities.

  • Focus on personal failings and negative outcomes.

  • Quickly lose confidence in personal abilities

The 4 sources of Self-Efficacy

How does self-efficacy develop? These beliefs begin to form in early childhood as children deal with a wide variety of experiences, tasks, and situations. However, the growth of self-efficacy does not end during youth, but continues to evolve throughout life as people acquire new skills, experiences, and understanding.


1. Mastery Experiences

"The most effective way of developing a strong sense of efficacy is through mastery experiences." Performing a task successfully strengthens our sense of self-efficacy. However, failing to adequately deal with a task or challenge can undermine and weaken self-efficacy.

2. Social Modeling

Witnessing other people successfully completing a task is another important source of self-efficacy. “Seeing people similar to oneself succeed by sustained effort raises observers' beliefs that they too possess the capabilities to master comparable activities to succeed” Support, challenge and develop the trainers and they will meet to share success, practice skills and calibrate assessments and they will take that process of learning into their work with for trainees.

3. Social Persuasion and connecting

Bandura also asserted that people could be persuaded to believe that they have the skills and capabilities to succeed. Consider a time when someone said something positive and encouraging that helped you achieve a goal. Getting verbal encouragement from others helps people overcome self-doubt and instead focus on giving their best effort to the task at hand. There lies the art of good feedback. But also the persuasion skills of Barack Obama and good leadership.

4. Psychological Responses and preparedness for the challenge

Our own responses and emotional reactions to situations also play an important role in self-efficacy. Moods, emotional states, physical reactions, and stress levels can all impact how a person feels about their personal abilities in a particular situation. A person who becomes extremely nervous before speaking in public may develop a weak sense of self-efficacy in these situations. However, "it is not the sheer intensity of emotional and physical reactions that is important but rather how they are perceived and interpreted" By learning how to minimize stress and elevate mood when facing difficult or challenging tasks, people can improve their sense of self-efficacy. Help create the right learning climate and in particular develop trainer’s groups that share, validate, support and problem solve.

Part of building self efficacy is good role modeling and use of the hidden curriculum. Develop the right environment and enthuse those around you.

But you also need to provide the facts, deal with the emotions, help set and picture achievable goals, develop through feedback and understand their and shared values. You need to be a persuader and stimulate behaviour

(With thanks to the Scottish Scaling the Heights Group – Edradour for helping develop these ideas and in particular Liz Barr for the role model template and Andy McPherson on self efficacy)


How to Teach Reflective Practice and use Kolb (16) and Schon (17).



  • Role model explicitly what you are doing and thinking when being observed. For example in a joint surgery identify what you are thinking at different moments in time. As one student said it is better for you to reflect out loud than for me to try to guess the thought bubbles coming out of your head. My experience is that patients also like this and join in if asked with their perspectives.



  • For a trainee who frequently just thinks about a patient’s disease take them on the patient’s journey. Explore with them the patient’s illness and the journey that individual takes from thinking about coming to see a doctor, what story they are planning in the waiting room, the consultation itself and what they will say to family, friends or work colleagues afterwards




  • Try some reflective writing and move from a descriptive narrative to one with some reflection and then to include feelings in the reflection. Ask a trainee to write a factual story describing a patient’s consultation. Then ask them to write down reflections about that individual patient. Then ask them to consider what feelings this might evoke in the patient and how they themselves felt during difficult parts of a consultation. What was it that made them feel better? For example was it something the patient said or a good question giving better insight or perhaps just safety netting? (Remind them of Helman’s folk model of the consultation.)




  • During case discussions share the benefits of time spent reflecting about what went on.




  • Help the learner understand that when we are sharing reflections they are the start of positive change and that this is not a summative assessment




  • Discuss the 5 levels of reflection.




  • 1 A description of what has happened, the learning event or the basic evidence data

  • 2 A description of what the learner’s response is to Level 1

    • What do they think of it?

    • What sense do they make of it?

    • What does it all mean to them?

    • How did it make them feel?

  • 3 A description of the learner’s awareness of the consequences or implications of

Level 1 on their practice of medicine, or their GP practice or their current

situation.



  • 4 A description of other information that relates to this such as

  • Research articles

  • Guidelines

  • Editorials or reviews

  • Conversations with experts




  • 5 A description of the changes that have actually occurred as a result of the above




  • Fully understand Kolb’s experiential learning cycle and simplify it so that it is easy for you and the trainee to understand and use


Kolb's learning theory sets out four distinct learning styles (or preferences), which are based on a four-stage learning cycle. (Which might also be interpreted as a 'training cycle'). In this respect Kolb's model is particularly elegant, since it offers both a way to understand individual people's different learning styles, and also an explanation of a cycle of experiential learning that applies to us all.

Kolb includes this 'cycle of learning' as a central principle for his experiential learning theory, typically expressed as four-stage cycle of learning, in which 'immediate or concrete experiences' provide a basis for 'observations and reflections'. These 'observations and reflections' are assimilated and distilled into 'abstract concepts' producing new actions which can be 'actively tested' in turn creating new experiences.

Kolb says that ideally this process represents a learning cycle or spiral where the learner 'touches all the bases', ie., a cycle of experiencing, reflecting, thinking, and acting. Kolb's model therefore works on two levels - a four-stage cycle:

  1. Concrete Experience - (CE)

  2. Reflective Observation - (RO)

  3. Abstract Conceptualization - (AC)

  4. Active Experimentation - (AE)

and a four-type definition of learning styles, (each representing the combination of two preferred styles, rather like a two-by-two matrix of the four-stage cycle styles, as illustrated below), for which Kolb used the terms:

  1. Diverging (CE/RO)

  2. Assimilating (AC/RO)

  3. Converging (AC/AE)

  4. Accommodating (CE/AE)





Note the match to Honey and Mumford

  1. 'Having an Experience' (stage 1), and Activists (style 1): 'here and now', gregarious, seek challenge and immediate experience, open-minded, bored with implementation.

  2. 'Reviewing the Experience' (stage 2) and Reflectors (style 2): 'stand back', gather data, ponder and analyse, delay reaching conclusions, listen before speaking, thoughtful.

  3. 'Concluding from the Experience' (stage 3) and Theorists (style 3): think things through in logical steps, assimilate disparate facts into coherent theories, rationally objective, reject subjectivity and flippancy.

  4. 'Planning the next steps' (stage 4) and Pragmatists (style 4): seek and try out new ideas, practical, down-to-earth, enjoy problem solving and decision-making quickly, bored with long discussions.

There is arguably a strong similarity between the Honey and Mumford styles/stages and the corresponding Kolb learning styles:

  • Activist = Accommodating

  • Reflector = Diverging

  • Theorist = Assimilating

  • Pragmatist = Converging

Consider how deep learning begats reflection and a facility for life long learning.

  • Do your own and encourage trainees to use PUNS and DENS (17) and at times both use Discomfort Logs. (18) Explore and share reflections on these

  • Consider what Reflection means to you and the trainee and consider the different types suggested by Schon.

SCHON'S THEORY OF REFLECTION

Donald Schon (1987) describes professional everyday practice as complex and not easily understood through technical rational models. He refers to this everyday practice as 'the swampy lowlands' of practice, i.e. everyday practice is messy, unpredictable, complex, challenging and stressful. Consequently, the professional practitioner needs to develop ways of understanding the everyday world of practice in order to learn from practice. There are three fundamental constructs in Schon's theory: knowing in action reflection in action reflection on action.


Knowing in action is the unconscious competence, intuitive knowing about or knowing how to do things. 'When we have learned how to do something, we can execute smooth sequences of activity, pattern recognition and decision making, without having to "think about it". Our spontaneous knowing in action usually gets us through the day. However, sometimes a familiar routine may produce something unexpected, that may just not feel right or where it is not possible to solve a problem using the usual strategies. Sometimes even if the problem has been solved, there is something odd about the result. In such situations, practitioners can either ignore the incident   or choose to reflect upon it. Repetitive practice may lead to problems such as no longer questioning the assumptions that underpin practice. Knowing in action alone may lead to missed opportunities to think about what they are doing and simply failing to see problems.


Reflection in action occurs at a time when you can still make a difference to the particular practice situation, i.e. it's 'on the spot' reflection. You may be surprised by an event in practice   an unexpected outcome, either pleasant or unpleasant   and find that your practice is interrupted by an immediate reflective response, that is, you are thinking about what you are doing as you do it. Reflection in action has a critical function, questioning the assumptions that underpin our knowing in-action. It gives rise to on the spot experimentation because of our awareness and observation of new phenomena or things that occur in our practice.


Reflection on action is something that you do after the event. You think back about what you have done in order to discover how your knowledge used in practice (knowing in action) and your reflection in action contributed to the outcome of your practice. Reflection on action has been widely applied in nursing practice and nursing curricula through a variety of approaches, such as 'reflective writing' (Holly, 1989), group reflection with nursing students (6etliffe, 1996), using art (Cruickshank, 1996) and critical incident analysis (Minghella and Benson, 1995). Your learning diary is, at least in part, a reflective diary too. As you have been making notes in your diary you have been reflecting on action. You may have been reflecting on something odd or puzzling, or you may hove chosen to reflect on everyday events that are not odd, or events that are significant at the time


  • Use awareness raising questions to trigger reflection and create the right culture for exploring them safely.




  • If a learner has difficulty reflecting you can again use logical levels




    • Environment – so for example it is too noisy or uncomfortable

    • Behaviour – this might be because reflective behaviour is a completely foreign concept and thinking remains rigid and structured

    • Capability – the trainee accepts that reflection is a good concept but have no idea how to do it properly

    • Beliefs – the trainee can reflect but believes it is a waste of time or that it is better not to reflect so that their internal feelings are not challenged

    • Identity – the trainee values their role as a diagnostician and has a conviction that doctors know all they need to know when they qualify.


And there is that highest Spiritual level starting to think beyond IQ and EQ and the balance of these of Spiritual intelligence will create deep level and probably life changing understanding of the core meaning of what we do.


The GROW model might help explore this and if you are helping a learner consider what awareness raising questions encourage reflection.

Establish the Goal
Define and agree the goal or outcome to be achieved. Ask them to reflect using questions like: "How will you know that you have achieved that goal?" "How will you know you are successful and the problem is solved?"

Examine Current Reality
Ask for reflection on things like "What is happening now?" "What, who, when, how often" "What is the effect or result of that?"

Explore the Options
What options or choices available? "What else could you do?" "What if this or that constraint were removed? "What are the benefits and downsides of each option?"
"What factors will you use to weigh up the options?

Establish the Will or Motivation Get your trainee to commit to specific action. In so doing, you will help them establish his or her will and motivation. "So what will you do now and when? "What could stop you moving forward?" "And how will you overcome it?" "Will this address your goal?" "How likely is this option to succeed?" "What else will you do?"


And finally Celebrate reflection and congratulate the learner when they do it. Hopefully in time it will become second nature and intuitive. That it becomes more than just an exploration of strengths and weaknesses but identifies and opens up an understanding of personal values, ideas, concerns, expectations, feelings and beliefs.


TEMPLATE FOR REFLECTION ON CONSULTATIONS

Give a brief factual description about the consultation




  1. What do you think the main issues needing addressed were?




  1. Which ones made sense to you and which were difficult?




  1. Which one do you think the patient meant you to think was the most important?




  1. How did you feel at the end of the consultation? (Anxious/angry/happy for example)



5. How do you think the patient felt

and what made you think they

felt like that?




What are the consequences or implications of what happened in the consultation?

  1. For you

  2. For the patient

  3. For the practice

  4. For others




What helped you make decisions or develop shared management plans?

For example research papers, editorials, guidelines, speaking to colleagues or the views of the patient.




What would you do differently next time

  1. If you were to perform this consultation again from the start

  2. If a different patient with a similar problem saw you






Again thanks to the Scottish Scaling the Heights Group – Edradour for helping develop these ideas. With particular thanks to Fiona Nicol and Roland Spencer-Jones for ideas on reflection and David Bee for ideas on Spiritual Intelligence.


And Gibbs Cycle of Reflection may be of help.


Gibb’s Reflective Cycle


Gibbs identified a series of 6 steps to aid reflective practice, these elements make up a cycle that can be applied over and over.


  • Description - what happened?

  • Feelings - what were you thinking and feeling?

  • Evaluation - what was good and bad about the experience?

  • Analysis - what sense can you make of the situation?

  • Conclusion - what else could you have done?

  • Action plan - what will you do next time?


Unlike many other models Gibbs takes in to account the realm of feelings and emotions which played a part in a particular event.




 MOTIVATIONAL INTERVIEWING


  • A negotiating style for helping people to change behaviour

  • Aims to increase internal motivation for change rather than impose change

  • Motivation when provided externally does not lead to long term adherence

  • Helps change by exploring and resolving ambivalence


Principles

Express empathy

  • Acceptance facilitates change

  • Skilful reflective listening is fundamental

  • Ambivalence is normal


Develop discrepancy

  • The argument for change comes from the person not you

  • Change is motivated by perceived discrepancy between present behaviour and important personal goals or values


Roll with resistance

  • Avoid arguing for change

  • Resistance is not directly opposed

  • New perspectives are invited, not imposed

  • Resistance is a signal to respond differently

  • The person is a primary resource in finding answers and solutions.


Support self efficacy

  • A person’s belief in the possibility of change is an important motivator

  • The person, not you, is responsible for choosing and carrying out change

  • Your belief in the person’s ability to change becomes a self-fulfilling prophecy


Key skills


  • Open ended questions

  • Affirmations

  • Reflective listening

  • Summarise

  • Elicit self motivational statements.


Stages of change


  • Pre-contemplation (Inactive and no intention to change)

  • Contemplation (Inactive, but intending to change in the next 6 months)

  • Preparation (Active but not regularly)

  • Action ( Regularly active, but only began in the last 6 months)

  • Maintenance (Regularly active for more than 6 months)


Look at how we change at the different stages


Ambivalence and the decisional balance


  • Current behaviour the pros and cons for staying the same

  • The pros and cons for change


Self efficacy is one’s capability to organize and execute the sources of action required to manage prospective situations. It does this by influencing


  • The choices we make

  • The effort we put in

  • How long we persist when we confront obstacles and face failure

  • How we feel


The sources of self efficacy


  • Mastery of experience (We get better by doing it better)

  • Vicarious experience (We get better by sharing in others experiences)

  • Social persuasion (including verbal persuasions and peer support)

  • Physiological states (We feel good when it goes well)



What do we do to influence the stages of change?


  • Pre-contemplation – Raise awareness

  • Contemplation – Tip the balance by evoking reasons for change and strengthen self efficacy

  • Preparation – Clarify goals plan course of action

  • Action – Help and advice to guide towards change and prevent relapse

  • Maintenance – Reinforce the benefit of change and identify and use resources to maintain goal



The processes of change cognitively


  • Give increased knowledge

  • Make aware of risks

  • Make aware of benefits

  • Look at consequences to others

  • Make aware of opportunities for change



The processes of change in behaviour strategies


  • Substitute alternatives

  • Enlist social support

  • Encourage they reward themselves

  • Encourage them to specify their commitment

  • Set up a system of reminders about the changes


The spirit of the method


  • Patient centred approach

  • Negotiation


Five key strategies (OARS)


  1. O Open ended questions

  2. A Affirmation

  3. R Reflective listening

  4. S Summarise

  5. Elicit self motivational statements


Open questions should


  • Be evocative and trigger an answer that is change talk

  • Avoid causing an answer that is resistant and committed to the status quo


Affirmation


  • The process of expressing genuine empathy, appreciation, understanding and support

  • Showing it with lots of positive reinforcement



Reflective listening


What the speaker says (Hearing) What the listener heard


(Encoding) (Decoding)


What the speaker means (Reflection) What the listener thinks the speaker

means


Reflection


A good reflective listening response is a statement and the inflection should turn down at the end


You is a good word


  • It sounds like you

  • So you feel

  • So you think that


Beware that your expertise, wisdom and experience doesn’t keep you from listening to their individual problem. Their understanding of the problem is what matters.


Levels of reflection


  1. Repeat Adds nothing and changes nothing

  2. Reword Substitutes a synonym for one component

  3. Paraphrase Gives back perceived meaning that has not been overtly stated

  4. Emotive A level 3 response that includes reflection of feeling

  5. Summary A reflection that brings together a number of previously stated

Elements


Reflection can be simple and communicates that you have heard the person and it is not your intention to get into an argument with them.

It can be amplified so you exaggerate what you have heard to try and trigger a response.

It can provide conflicting statements that have been given one noting resistance and another with a statement that change is desired.

Affirming statements can make positive empathic points of support. (E.g. “That must have been difficult for you” or “That’s a good suggestion”)

Summarising statements reflect the key points made.


Eliciting change talk


  • DESIRE I want to---

  • ABILITY I can---

  • REASONS I feel there are good reasons for me to---

  • NEED I really need to---

  • READINESS I’m ready to do this---

  • COMMITMENT I’m going to---


How do we elicit change talk?


Use EVOCATIVE QUESTIONS that trigger a response


  • EXTREMES What is the worst thing that could happen?

  • LOOK BACK What were things like before the problem?

  • LOOK FORWARD What will they be like after you change?

  • EXPLORE GOALS And look at the discrepancy between important

goals and the behaviour

  • ELABORATION Helps reinforce the motivation to change


Are they ready to change?


Look at the PROS and CONS of change versus no change


PROS CONS




Change





No change


Assessment of readiness


On a scale of 1-10 how motivated are you to change?

You say you are a 4. Why is this not a 1 and what would move you to 10?


On a scale of 1-10 how confident are you that you can change?

Why a 5 and not a 2 and what do you need to take your confidence to a 10?


Motivation to change


0-------------------------------------------------10


Confidence to change


0-------------------------------------------------10

BRIEF NEGOTIATION MODEL based on Motivational interviewing


  1. GROUNDWORK (Why are you here today? How can I help?)




  1. OARS

    • Open questions to explore ambivalence

    • Affirm person’s comments

    • Reflective listening

    • Summarise


3 WHAT IS YOUR TYPICAL DAY?


4 DECISIONAL BALANCE (Pros and Cons)


5 ASSESSMENT OF READINESS (Motivation of how important and how

confident?)


6 GOOD THINGS V NOT SO GOOD THINGS (Benefit v possible disadvantage)


7 SUMMARISE (And create discrepancy and cognitive dissonance) (So you want

to do this but are concerned at the amount of time it will take)


8 ACTION PLANNING

  • Are they willing and able to begin to consider action?

  • Do you have appropriate advice to offer?

  • Do they have the opportunity? (I.e. the financial, physical or emotional

capability)

  • Set SMART goals


Throughout use GOOD COMMUNICATION SKILLS.


With thanks to David Bee (Associate Adviser GP Unit SE Scotland) for helping develop ideas on Motivational Interviewing.


Set SMARTIES GOALS and use them to look at PROCESS and OUTCOME


S Specific What is it specifically that I want to achieve or learn. You may need to break down a general aim into several specific statements each of which is a step , or a part of the overall Aim. (eating a chocolate bar do you eat a chunk at a time or try it all in one go? CHUNK AND CHECK.


M Measurable How will I know that I have learnt this or achieved my objective? When will I know I don’t have to go on with this taking it further? Where am I now and where do I want to be (exactly!)


A Achievable Is it all possible? How am I going to achieve this?


R Relevant Is it relevant to my career? Is it more relevant to do it now or later? Is this a hangover from a former career intention that I need to review? A need or a want?


T Time By what time will I be able to demonstrate that I have achieved this? What is my time limit on this plan?
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