Motivating Change 2: Next Steps

Trainer Outline (updated 2016)

Time / Topic /

Facilitator

8:00 /
  • Sign-in
  • Participants Chart pad from pre-work:
Challenging situations / behaviors
Pt statements that stop you in your tracks
8:30 /
Introduction and Overview
Welcome & Introductions
  • Ruler: “How confident are you in your ability to use MC skills effectively in your practice?” Place blue sticker on ruler.
  • Objectives and Agenda Review
  • Participant Expectations
  • Binder review if needed
  • What have you practiced from MC 1?

9:00 / BN Roadmap Review: The Giant Brain
(Handout roadmap to support the activity.)
Activity:
  • One facilitator will play the role of the patient, the other facilitator will be the “clinician’s voice”, participants are “the clinician’s brain”
  • The “clinician’s voice” sets up the scenario: I will be working with a patient who has high cholesterol. You will tell me how to construct the encounter, step by step. Take the Cholesterol Management Option Tool from the flap in your binder, then close your binder. This patient’s lab values are as follows: Chartpad labs:
2 weeks ago: 6 months ago:
TC 260 (<200) TC 280
HDL 32 (>40) HDL 30
LDL 150 (<130) LDL 168
  • I’ve never met this patient before. What shall I do to open the encounter?
  • Elicit ideas from participants, prompt as needed, then deliver the opening.
  • How did I do? Discuss briefly as needed. What should I do next?
  • Continue this pattern through the encounter, coaching as needed to bring out main points of the Roadmap.
  • Debrief the bigger picture at the end as needed. Reinforce DARN CATS change talk, resolving ambivalence, BN style
/ Smoking
Unsure
9:45 /

Break

10:00 / The BN Method: Clinician & Patient
Goal: practice delivering and receiving the model. Hone understanding of change talk / sustain talk in a conversation when the speaker is ambivalent. Identify your growing edge in the model and where you feel strongest.
Instructions:
  • Partner with someone you don’t know
  • Each person will have an opportunity to be both patient and clinician
“Patients”
  • Use your own personal issue from the pre-work: something you feel ambivalent about changing (health related)
  • Tell your partner in a sentence or two what the issue is
  • Offer genuine responses as the clinician guides you through the BN process
“Clinicians”
  • Have your tools ready: Roadmap, Ruler, Option Tools
  • Using the roadmap, assist your partner to work through the roadmap, remembering to evoke and reflect change talk.
  • Remember the central skills of ask, listen and summarize
  • You may or may not negotiate the agenda, depending on the complexity of your partner’s issue Use one of the pre-printed option tools or quickly work together to create a custom option tool based on your partner’s issue as needed.
Activity:
  • Allow 7 -10 minutes in each role
  • Circulate and coach as needed
  • Debrief after both cycles complete
  • Key Questions for Debrief:
Patients:
What about this encounter was powerful for you personally?
What have you learned that gives you insight into your patients’ experience with ambivalence and change?
Providers:
What were your successes?
Your challenges?
What did you learn about the clinician’s role in BN that you will take back to your clinical practice? / Open – Ask Permission & use strategic questions:
-Open Qs
- Change talk evoking
- Elicit strengths & past success
Focus/negotiate agenda to target behavior.
Ruler
1-2 Change Qs
Tailor
Close
10:45 / Listening for the Story link to debrief of previous activity
  • Listening specifically for change talk (and Sustain talk) supports your understanding of the patients perspective.
  • Show Change talk/Sustain talk slide
  • Reinforce LISTENING as central to working effectively to support health behavior change
  • How does listening build motivation? Creates environment to assist pt to explore / discover own solutions, communicates caring, builds rapport, supports collaboration, encourages self-care, etc.
Activity: Finding Change Talk in Pt Statements
Goal: Identify CT & ST in patient statements (slides)
Key message: As providers we often focus on sustain talk and work to ‘trouble shoot barriers’ prematurely.
Building our listening skills to hear valuable change talk, and acknowledging the normal role sustain talk plays in a conversation about change.
Wrap up: Part of working effectively with patients is listening to their story and, based on who they are and the strengths and limitations they bring to the issues at hand, assisting them to build motivation for behavior change.
Play video: It’s Not About the Nail.
11:15 /
Reflective Listening – learning to craft an effective reflection
Present Gordon’s Model of Communication – are we hearing right? What does it mean? Underscores the complexity of communication.
  • Introduce Reflective Listening as one tool to enhance effective communication and ensure ones understand of the speaker’s perspective. Reflections help to evoke deeper change language and demonstrate an empathic, neutral style. Holding a mirror, statement not question.
  • Introduce guidelines for Reflective Listening statements and Levels of Reflection
There are several levels of reflection, which can be used strategically to support a change conversation.
  • In MI, learning to identify a pts change talk and reflect it serves to amplify their change language and for pts who are not ready for change, feeling reflections serve to build rapport and demonstrate empathy.
Activity: Reflections Worksheet
In partners, complete the reflections worksheet. Debrief with large group.
Show Raymond video as an example of reflections
Activity 2: Reflective Listeningusing Reflection Stems
  • Introduce and demonstrate “Something about myself I’d like to change is………” “You feel………”
Share reflection Stems: You…You feel…From your perspective…In your view…
  • Encourage choosing something meaningful
  • Speaker is encouraged to elaborate
  • Practice in 2 small groups, first round listeners offer 1 feeling reflection, second round, listeners offer 2 reflections and a strategic open questions. (see examples below).
  • Let everyone who wants to have a turn being the speaker
  • Debrief in small groups
  • Back in the large group,View Brene Brown Empathy vs Sympthay video. review p.16 Chinese Symbol for listening
/ Resource Manual p. 22
Reflection worksheet (feelings)
Resource Manual pp. 23-26
12:15 /

Lunch

1:00 / Video Clip: The Rounder(aka Responding to Resistance, Terri Moyerson YouTube)
  • Introduce the video, goal is to highlight reflections, neutral style, and open questions.
  • Observe clinician and watch forexamples of:
Open Ended Questions
Reflective statements
Evoke change talk
  • Show video
  • Quick Debrief
What was the impact of Terry’s neutral stance on the client’s willingness to discuss his issues?
How did she build rapport?
What are some examples of change talk in this encounter?
What was the pivotal moment in the encounter?
1:30 / Batting Practiceto engage the NOT Ready or Upset Patient
  • Like “The Rounder”, your patients sometimes offer challenging statements.Review "Pt statements that stop you in your tracks" add to list as needed.
Activity:
  • Introduce activity: A chance to practice responding to “show-stoppers” with reflective listening
  • Conduct activity with whole group – everyone has an opportunity to pitch and bat: emphasize choice: okay to sit on the bench
  • Participants get up and form a semi-circle in front of the tables. Batter stands in front of the “U”. First pitcher faces the batter and delivers the “pitch”– then rotates to batting position when finished pitching. Batter returns to the semi-circle
  • Pitchers can use statements from chart pad, or draw from bucket of balls
  • Batters may ask for coaching / let it go by, etc.
  • Debrief as you go
  • Keep this activity moving at a fast pace - - create a climate for play/fun
  • Round #2: 2 reflections and a strategic Question

2:15 / Break
2:30 / Reflective Listening & The Roadmap
  • Opportunity to practice assessing readiness and exploring ambivalence incorporating reflective listening. Aim for 2-3 reflections for each open-ended question in the yellow boxes on the map
Instructions:
•Invite participants to create triads. Each person will have the opportunity to be patient, provider, and observer. Consider writing instructions on chartpad:
“Clinicians”:
  • Tell the patient who they are: consider using a typical patient from your practice.
  • Let the patient know the diagnosis AND the specific topic for discussion, eg: Hypertension, focus on exercise
  • Assess readiness and explore ambivalence, doing your best to offer 2-3 reflections after every open-ended question. Chart pad reminder: ASK-LISTEN-REFLECT-LISTEN-REFLECT-LISTEN-REFLECT
  • A Trainer will stay with each group for one full cycle to provide coaching and feedback
“Patients”:
  • Be ambivalent about making the change (4-5-6 on ruler)
  • Verbalize the pros and cons of adopting the behavior
  • Elaborate / offer deeper reasons when your partner offers a reflection
Observers:
  • On page 80-81, use the grid to track: OEQs, CEQs, Reflections, Change Talk.
  • Be prepared to provide feedback to the provider
Activity:
  • Allow 10 minutes for each patient interaction, then 5 minutes for debrief - - monitor time closely
  • Ensure that each group receives one full cycle with a trainer for extra coaching and feedback
  • After all cycles are complete, debrief in large group: Ask each group to share one or two key learnings
  • Before the break, invite participants to place green dots on the ruler

3:30 / Panel Discussion
  • Check expectations from the morning, address gaps as needed
  • Each participant share key learnings and next steps for enhancing MC skills
  • Invite participants back to the ruler. Review dots and briefly discuss. To what do you attribute the shift? Did anyone move down the ruler? Would you be willing to tell us a bit about that?

4:10 / Summary, Evaluation & Close
  • Describe online MC programs and distribute online program flyers
  • Distribute Evaluations
  • Remind participants to sign out

4:30 / Adjourn

Notes:

REGIONAL HEALTH EDUCATION