Art & science
If you would like to contribute to the Art & science section, email [email protected]
The synthesis of art and science is lived by the nurse in the nursing act
Josephine G Paterson
Promoting health: making every contact count Percival J (2014) Promoting health: making every contact count. Nursing Standard. 28, 29, 37-41. Date of submission: September 9 2013; date of acceptance: October 18 2013.
Abstract This article describes a new training programme devised and run by the Royal College of Nursing (RCN) to assist staff to make every patient contact count. The aim of the training programme is to help nurses become more effective when offering opportunistic health promotion advice as part of their routine work, and avoid generating resistance to change.
Author Jennifer Percival RCN tobacco policy adviser and trainer, and independent consultant, Hertfordshire. Correspondence to: [email protected]
Keywords Behaviour change, communication, health promotion, patient interactions, public health
Review All articles are subject to external double-blind peer review and checked for plagiarism using automated software.
Online Guidelines on writing for publication are available at www.nursing-standard.co.uk. For related articles visit the archive and search using the keywords above.
ALL NURSING STAFF are required to carry out public health activities and deliver public health messages as part of everyday NHS care. Nurses have been advised that every interaction with a patient should be seen as an opportunity to promote health and prevent illness (Royal College of Nursing (RCN) 2012).
© NURSING STANDARD / RCN PUBLISHING
The summary report from the NHS Future Forum (2012) states that ‘Every healthcare professional should “make every contact count”: use every contact with an individual to maintain or improve their mental and physical health and wellbeing where possible, in particular targeting the four main lifestyle risk factors: diet, physical activity, alcohol and tobacco – whatever their specialty or the purpose of the contact’. The report advises that the ideal of making every contact count should be incorporated into the NHS Constitution as a core staff responsibility, and identifies the need for skills training and support to implement the new health promotion activities (NHS Future Forum 2002). In response to these recommendations, the RCN piloted, and then implemented, a specialist one-day workshop for all nurses. It was especially relevant to those working in public health, including health visitors and school nurses. The training was entitled Making Every Contact Count: Having the Difficult Conversation. The workshop was devised and run by the author, who recognised that for NHS staff to make every contact count they would benefit from attending a course based on counselling techniques. This article outlines the theoretical underpinning of the workshop, and the main messages and content.
Pilot workshops Before the launch of the RCN Making Every Contact Count workshop, pilot workshops were held in London and Manchester. Participants were recruited through an article in the RCN Bulletin. Before attending training provided in the workshops, the 40 nurse participants were required to complete a questionnaire devised by the RCN’s learning and development department, march 19 :: vol 28 no 29 :: 2014 37
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Art & science behaviour change to assess their training needs and explore their past experiences of helping the public to change their lifestyle or health behaviours. The main issues participants reported were: The complexity of gauging people’s motivation to change. The frustration of working with people who wanted a ‘quick fix’ to their health problems. Difficulty in dealing with people who did not listen. Feeling challenged by resistant or defensive behaviour. Working in a time-pressured environment. Being expected to motivate people to change when they were not ready to receive advice. These findings demonstrated the challenges experienced by a range of practitioners and were used to finalise the content of the 2013 RCN workshop. In the questionnaire, participants acknowledged the limitations of diagnosing a problem and offering behaviour change advice as a solution; and many commented that such unproductive discussions were a waste of time. The specific conversations described as frustrating by participants, before they attended the RCN workshop, were those with patients who: Seek medical advice and treatment, yet continue to undermine their health by making poor lifestyle choices. Attend clinics for support to reduce their weight, but do not follow the action plans provided. Need to change their lifestyle, but present barriers to the recommendations provided continually. Always have an answer as to why the suggestions made will not work for them.
Workshop design To help the workshop participants deal with challenging situations and difficult conversations, a more effective range of communication strategies needed to be identified and explained. Current evidence to show how a healthcare professional can effectively help someone change in a short period of time is limited. The theoretical content of the RCN Making Every Contact Count workshop was taken from the communication strategies found to be effective in person-centred therapy, the stages of change model and motivational interviewing.
Person-centred therapy
Carl Rogers first defined person-centred therapy in 1951, the basic principle of which is that therapists should enable patients to find their own solutions to their problems rather than imposing solutions on them. Rogers (1961) believed that successful therapy is achieved by creating the right 38 march 19 :: vol 28 no 29 :: 2014
environment, whereby a person feels confident in the therapist and able to trust that he or she is being listened to and treated with integrity, while a therapist needs to display congruence (striving to be open and honest and able to share their thoughts and feelings), unconditional positive regard and empathy. Rogers (1961) did not endorse telling clients what they should do, because he believed that the individual was more likely to have the solution to his or her problem. Instead, he identified the need for therapeutic relationships in which the therapist focuses on exploring the internal frame of reference of the individual (Rogers 1961). Rogers (1961) felt the therapist’s role was to create a facilitative, empathic environment in which the client could discover his or her own answers to his or her problems. The term person-centred is being used increasingly in nursing practice to describe placing the patient at the centre of care delivery (McCance et al 2011).
Stages of change model
The behaviour change model first devised by Prochaska and DiClemente in 1983 became known as the stages of change model and was used to support many behaviour modification techniques, including those associated with smoking, alcohol and illicit drug use (Prochaska and DiClemente 1986). The model describes how behaviour change is a process during which a person goes through a series of five predictable stages (Box 1), and relapse can occur during any of these stages (Prochaska and DiClemente 1986). The stages of change model helps practitioners to perceive change as a complex process and understand why providing the ‘right advice’ is not enough (Prochaska and DiClemente 1986). Many people set themselves goals, for example making new year’s resolutions, that fail. People want the outcome they promised themselves; it is changing their behaviour to achieving these goals that is difficult. The stages of change model shows how a person needs to believe that changing his or her behaviour is advantageous for him or herself – and that he or she wants to put effort into making this happen by deciding when, what and how to change – before change can take place.
Motivational interviewing
More than 200 randomised controlled trials have shown that motivational interviewing can encourage behaviour change in various healthcare settings, and improve the relationship between patients and practitioners as well as the efficiency of the consultation (Miller and Rollnick 2010). National Institute for Health
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and Care Excellence (2008) guidelines on smoking cessation also recommend using motivational interviewing techniques. Motivational interviewing is a patient-centred style of counselling that aims to achieve behaviour change by helping people to explore and resolve their ambivalence to change. Telling patients what they should do, persuading with logic, arguing, lecturing, giving advice or providing solutions are the conceptual opposite of motivational interviewing (Rollnick et al 2008). Compared with Rogers’ (1961) non-directive approach, motivational interviewing is more focused and goal-directed. The five general principles of motivational interviewing are listed in Box 2. Motivational interviewing is a method of communication, which uses a guiding style to engage patients, help them to clarify their strengths and aspirations, identify their motivation for change and promote confidence in their decision making (Rollnick et al 2008). It has been adapted for use by many non-specialists across a range of healthcare settings. The main messages taken from the three communication strategies described in this section and included in the RCN Making Every Contact Count workshop were: The way we speak to people is likely to be as important as what we say. Being listened to and understood is an important part of the change process. People are responsible for the choices they make and any actions they take. The person who has the problem is also the person who can solve it. People only change their behaviour when they feel ready to do so. The solutions people find for themselves are the most enduring and effective.
BOX 1 Stages of change model 1. Pre-contemplation stage (contented) The person sees many advantages in his or her current behaviour. The person has no interest in changing his or her behaviour. 2. Contemplation stage (considering change) The person thinks about the advantages and disadvantages of changing his or her behaviour. He or she acknowledges some dangers and risks. He or she still has many reasons for continuing current behaviour. 3. Preparation stage (acknowledging the benefits of change) The person realises that change is beneficial. He or she believes that change is possible to achieve. He or she makes plans to change. He or she takes steps towards change. 4. Action stage (making the change) The person changes his or her behaviour. 5. Maintenance (sustaining change) The person continues to implement the change. He or she copes without relapse. He or she deals with temptation. (Prochaska and DiClemente 1986)
BOX 2 Five general principles of motivational interviewing Seeking to understand the person’s frame of reference, particularly using reflective listening. Expressing acceptance and affirmation. Eliciting and selectively reinforcing the person’s self-motivational statements, expressions of problem recognition, concern, desire and intention to change, and ability to change. Monitoring the person’s readiness to change, and ensuring that resistance is not generated by jumping ahead of him or her. Affirming the person’s freedom of choice and self-direction. (Rollnick et al 2008)
Workshop programme The RCN Making Every Contact Count workshop combined theoretical presentations, group discussions, an explanation of how the techniques adopted from other therapies could be used to good effect in clinical practice, experiential learning, and practice through working together in pairs on a range of set tasks. The workshop was attended by staff from a variety of areas, including education, general nursing, practice nursing, community health, sexual health, occupational health, school nursing and health visiting. Six training events were carried out in 2013 across the UK. To achieve the aims of the workshop, participants were shown how to:
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Use reflective listening skills to understand how the person perceives his or her issue or problem. Demonstrate acceptance and understanding of the situation. Clarify the presenting issue through open questions and reflection. Elicit and reinforce the person’s self-motivational statements. Listen for their understanding of a desire to change. Assess the person’s concerns, desires, intentions, and belief in his or her ability to change. Avoid generating resistance or arguments by pressuring the person to take action before he or she is ready. march 19 :: vol 28 no 29:: 2014 39
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Art & science behaviour change Affirm the person’s freedom of choice and self-responsibility to change. Recognise that a person’s readiness to change is often experienced as a fluctuating state of mind. Participants worked together in pairs to explore the limitations of asking closed questions and giving advice. The benefits of effective listening, asking open questions, clarifying people’s meanings and providing a summary of the conversation were demonstrated. For some participants this refreshed previous training on communication skills, but for most the information was new. Participants were encouraged to do further reading on the subject to develop their confidence in applying these techniques. A series of interactive experiential learning exercises enabled participants to practise listening, asking questions, reflection and clarification and summarising techniques.
Listening
Participants were asked to give the person space to talk and to practise listening without judgement, interruption, advice giving or making assumptions. The main teaching point of this exercise is that allowing a person to talk about the issue he or she wishes to discuss, from his or her perspective and without interruption, develops rapport (Rogers 1961).
Asking questions
Participants were asked to use simple open questions to encourage people to explain their situation in
BOX 3 Practitioners’ responses to challenging patient statements Patient: ‘I don’t think my diet is affecting my health, I’m eating less and I don’t feel better.’ Practitioner: ‘What made you decide to change your diet?’ ‘How did you do this? How did you hope to feel?’ ‘What have you heard about the problems of a poor diet?’ ‘Have you any concerns about what might happen to you if you don’t lose weight?’ ‘So you have some mixed feelings about your new diet?’ ‘What do you think is causing the problem?’ Patient: ‘Quitting smoking is much more difficult than I expected.’ Practitioner: ‘It sounds like you have been trying hard to make a change.’ ‘Why did you decide to stop?’ ‘What is the longest time you stopped for?’ ‘How did you manage this?’ ‘Are you using any medication to help?’ ‘What kind of support do you have?’ ‘Do you have any concerns about what might happen if you don’t stop?’
40 march 19 :: vol 28 no 29 :: 2014
their own words and from their perspective. The main teaching points of this exercise were that the way in which a question is posed can influence the quality and quantity of information provided. Some questions encourage the person to speak and others limit the amount of information offered (Rollnick et al 2008). Participants were encouraged to seek permission before providing advice because this helps the patient feel in control of the consultation. For example: ‘Would it be okay if I shared some strategies that have worked for others?’ (Miller and Rollnick 2010).
Reflection and clarification
Participants were asked to give feedback on the main points they had heard during the conversation exercises and include any non-verbal clues they had observed. On hearing the feedback, participants reported feeling valued and were surprised at the amount of information they had shared. The main teaching points of this exercise were: Providing feedback helps the person know you are listening and gives him or her an opportunity to reflect on the situation. People are more likely to share information when they feel heard and respected (Rollnick et al 2008).
Summarising
Participants were invited to discuss a change they wished to make. Their learning partners were asked only to use the techniques of listening, asking questions and providing a summary. They were instructed not to offer advice or suggestions. After this exercise, participants acknowledged that it felt good to be listened to and to be able to speak without interruption. They also recognised that they had the skills to identify their own solutions and that many patients could probably do the same with their support. The main teaching point of this exercise was that although it can take time and skill to help a person to identify a solution, a plan or idea he or she has thought of is more likely to be used (Rollnick et al 2008).
Applying the workshop techniques to practice The workshop participants were given the opportunity to address a range of situations where they might find patients’ responses challenging or frustrating.
Responding to challenging statements
To help participants apply their training to clinical practice, they were asked to respond to a series of challenging statements using open questions and reflection. The findings in Box 3
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show the effectiveness of the communication skills training exercises.
Responding to resistance to change
To address the frustration expressed commonly by staff when working with people who choose not to change, participants were shown how to work with people who they had described previously as ‘resistant to change’. The communication techniques recommended were to use open questions to identify what the problem means to the person and clarify his or her understanding of the risks posed to his or her health. Participants then worked in small groups to practise applying these techniques using role play scenarios. An example of how one participant implemented this exercise in clinical practice is shown in Box 4.
Post-course evaluation
Six Making Every Contact Count workshops were run in 2013 and further workshops may be available, depending on demand. The RCN nursing department conducted a post-workshop evaluation via email 12 weeks after each of the workshops. The survey found that the workshops had provided the majority of participants with practical examples of interviewing techniques and conversation starters.
These participants were able to ask patients different questions. Although this did not make the task of asking difficult questions easier, it did change the way participants approached this previously challenging area of work. Participants’ communication tactics now focused on using more encouraging, thoughtprovoking questions. The majority of the participants believed that the training had made it easier for them to have difficult conversations with patients.
Conclusion Increasing pressure on staff to address people’s poor lifestyle choices, and the frustrations they experience when they try to promote health, has left many nurses feeling frustrated and unconfident in this area of work. Providing staff with additional communication skills training can help address these problems and improve the motivation and confidence of nurses to undertake their role as providers of healthcare advice NS Acknowledgement The author would like to thank the Department of Health and Slimming World for providing sponsorship to support the RCN Making Every Contact Count workshops.
BOX 4 Participant’s case report after attending the Making Every Contact Count workshop ‘Prior to the RCN training I often felt frustrated when I saw a person’s health deteriorating because I knew it could be prevented easily if the person would amend his or her lifestyle. I saw my role in occupational health to provide information on staff current health status, any deterioration I had charted since their last visit, and to provide some facts/advice on the steps they needed to take to improve their health or fitness to fulfil the requirements of their role at work. I did not push and I thought my help was not needed if I was not asked. On follow-up visits I was anxious not to be confrontational, so avoided challenging any lack of action. Since the training, I understand that providing information is not enough to support a person to change their
behaviour and have adopted a partnership approach. I share my observations and concerns about my findings and give staff time to express their reaction to the results. Rather than telling them what they can do, I ask if they are happy for me to make some suggestions. I found this works well. I no longer feel like I am lecturing. Next, I ask about any concerns, fears or barriers they have about implementing the changes required. I explore what they think they can do differently, who might be able to support them and when they might start the changes. It has made a huge difference. The questions I ask now are different. Staff who previously said little, are now happy to set goals and talk through their plans with me.’
References McCance T, McCormack B, Dewing J (2011) An exploration of person-centredness in practice. Online Journal of Issues in Nursing. 16, 2, 1. Miller B, Rollnick S (2010) What’s New Since MI-2? www.motivationalinterview.org/ Documents/Miller-and-Rollnickjune6-pre-conference-workshop.pdf (Last accessed: February 26 2014.) National Institute for Health and Care Excellence (2008) Smoking
Cessation Services in Primary Care, Pharmacies, Local Authorities and Workplaces, Particularly for Manual Working Groups, Pregnant Women and Hard to Reach Communities. NICE Public Health Guidance 10. NICE, London. NHS Future Forum (2012) NHS Future Forum Summary Report: Second Phase Overarching Report. www.gov.uk/government/ publications/nhs-future-forum-
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recommendations-to-governmentsecond-phase (Last accessed: February 26 2014.) Prochaska JO, DiClemente CC (1986) Towards a comprehensive model of change. In Miller WR, Heather N (Eds) Treating Addictive Behaviors: Processes of Change. Plenum Press, New York NY, 3-27. Rogers CR (1961) On Becoming A Person: A Therapist’s View of
Psychotherapy. Houghton Mifflin, Boston MA. Rollnick S, Miller WR, Butler CC (2008) Motivational Interviewing in Health Care: Helping Patients Change Behavior. The Guilford Press, New York NY. Royal College of Nursing (2012) Going Upstream: Nursing’s Contribution to Public Health. Prevent, Promote and Protect. RCN, London.
march 19 :: vol 28 no 29:: 2014 41
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If you would like to contribute to the Art & science section, email [email protected]
The synthesis of art and science is lived by the nurse in the nursing act
Josephine G Paterson
Promoting health: making every contact count Percival J (2014) Promoting health: making every contact count. Nursing Standard. 28, 29, 37-41. Date of submission: September 9 2013; date of acceptance: October 18 2013.
Abstract This article describes a new training programme devised and run by the Royal College of Nursing (RCN) to assist staff to make every patient contact count. The aim of the training programme is to help nurses become more effective when offering opportunistic health promotion advice as part of their routine work, and avoid generating resistance to change.
Author Jennifer Percival RCN tobacco policy adviser and trainer, and independent consultant, Hertfordshire. Correspondence to: [email protected]
Keywords Behaviour change, communication, health promotion, patient interactions, public health
Review All articles are subject to external double-blind peer review and checked for plagiarism using automated software.
Online Guidelines on writing for publication are available at www.nursing-standard.co.uk. For related articles visit the archive and search using the keywords above.
ALL NURSING STAFF are required to carry out public health activities and deliver public health messages as part of everyday NHS care. Nurses have been advised that every interaction with a patient should be seen as an opportunity to promote health and prevent illness (Royal College of Nursing (RCN) 2012).
© NURSING STANDARD / RCN PUBLISHING
The summary report from the NHS Future Forum (2012) states that ‘Every healthcare professional should “make every contact count”: use every contact with an individual to maintain or improve their mental and physical health and wellbeing where possible, in particular targeting the four main lifestyle risk factors: diet, physical activity, alcohol and tobacco – whatever their specialty or the purpose of the contact’. The report advises that the ideal of making every contact count should be incorporated into the NHS Constitution as a core staff responsibility, and identifies the need for skills training and support to implement the new health promotion activities (NHS Future Forum 2002). In response to these recommendations, the RCN piloted, and then implemented, a specialist one-day workshop for all nurses. It was especially relevant to those working in public health, including health visitors and school nurses. The training was entitled Making Every Contact Count: Having the Difficult Conversation. The workshop was devised and run by the author, who recognised that for NHS staff to make every contact count they would benefit from attending a course based on counselling techniques. This article outlines the theoretical underpinning of the workshop, and the main messages and content.
Pilot workshops Before the launch of the RCN Making Every Contact Count workshop, pilot workshops were held in London and Manchester. Participants were recruited through an article in the RCN Bulletin. Before attending training provided in the workshops, the 40 nurse participants were required to complete a questionnaire devised by the RCN’s learning and development department, march 19 :: vol 28 no 29 :: 2014 37
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Art & science behaviour change to assess their training needs and explore their past experiences of helping the public to change their lifestyle or health behaviours. The main issues participants reported were: The complexity of gauging people’s motivation to change. The frustration of working with people who wanted a ‘quick fix’ to their health problems. Difficulty in dealing with people who did not listen. Feeling challenged by resistant or defensive behaviour. Working in a time-pressured environment. Being expected to motivate people to change when they were not ready to receive advice. These findings demonstrated the challenges experienced by a range of practitioners and were used to finalise the content of the 2013 RCN workshop. In the questionnaire, participants acknowledged the limitations of diagnosing a problem and offering behaviour change advice as a solution; and many commented that such unproductive discussions were a waste of time. The specific conversations described as frustrating by participants, before they attended the RCN workshop, were those with patients who: Seek medical advice and treatment, yet continue to undermine their health by making poor lifestyle choices. Attend clinics for support to reduce their weight, but do not follow the action plans provided. Need to change their lifestyle, but present barriers to the recommendations provided continually. Always have an answer as to why the suggestions made will not work for them.
Workshop design To help the workshop participants deal with challenging situations and difficult conversations, a more effective range of communication strategies needed to be identified and explained. Current evidence to show how a healthcare professional can effectively help someone change in a short period of time is limited. The theoretical content of the RCN Making Every Contact Count workshop was taken from the communication strategies found to be effective in person-centred therapy, the stages of change model and motivational interviewing.
Person-centred therapy
Carl Rogers first defined person-centred therapy in 1951, the basic principle of which is that therapists should enable patients to find their own solutions to their problems rather than imposing solutions on them. Rogers (1961) believed that successful therapy is achieved by creating the right 38 march 19 :: vol 28 no 29 :: 2014
environment, whereby a person feels confident in the therapist and able to trust that he or she is being listened to and treated with integrity, while a therapist needs to display congruence (striving to be open and honest and able to share their thoughts and feelings), unconditional positive regard and empathy. Rogers (1961) did not endorse telling clients what they should do, because he believed that the individual was more likely to have the solution to his or her problem. Instead, he identified the need for therapeutic relationships in which the therapist focuses on exploring the internal frame of reference of the individual (Rogers 1961). Rogers (1961) felt the therapist’s role was to create a facilitative, empathic environment in which the client could discover his or her own answers to his or her problems. The term person-centred is being used increasingly in nursing practice to describe placing the patient at the centre of care delivery (McCance et al 2011).
Stages of change model
The behaviour change model first devised by Prochaska and DiClemente in 1983 became known as the stages of change model and was used to support many behaviour modification techniques, including those associated with smoking, alcohol and illicit drug use (Prochaska and DiClemente 1986). The model describes how behaviour change is a process during which a person goes through a series of five predictable stages (Box 1), and relapse can occur during any of these stages (Prochaska and DiClemente 1986). The stages of change model helps practitioners to perceive change as a complex process and understand why providing the ‘right advice’ is not enough (Prochaska and DiClemente 1986). Many people set themselves goals, for example making new year’s resolutions, that fail. People want the outcome they promised themselves; it is changing their behaviour to achieving these goals that is difficult. The stages of change model shows how a person needs to believe that changing his or her behaviour is advantageous for him or herself – and that he or she wants to put effort into making this happen by deciding when, what and how to change – before change can take place.
Motivational interviewing
More than 200 randomised controlled trials have shown that motivational interviewing can encourage behaviour change in various healthcare settings, and improve the relationship between patients and practitioners as well as the efficiency of the consultation (Miller and Rollnick 2010). National Institute for Health
© NURSING STANDARD / RCN PUBLISHING
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and Care Excellence (2008) guidelines on smoking cessation also recommend using motivational interviewing techniques. Motivational interviewing is a patient-centred style of counselling that aims to achieve behaviour change by helping people to explore and resolve their ambivalence to change. Telling patients what they should do, persuading with logic, arguing, lecturing, giving advice or providing solutions are the conceptual opposite of motivational interviewing (Rollnick et al 2008). Compared with Rogers’ (1961) non-directive approach, motivational interviewing is more focused and goal-directed. The five general principles of motivational interviewing are listed in Box 2. Motivational interviewing is a method of communication, which uses a guiding style to engage patients, help them to clarify their strengths and aspirations, identify their motivation for change and promote confidence in their decision making (Rollnick et al 2008). It has been adapted for use by many non-specialists across a range of healthcare settings. The main messages taken from the three communication strategies described in this section and included in the RCN Making Every Contact Count workshop were: The way we speak to people is likely to be as important as what we say. Being listened to and understood is an important part of the change process. People are responsible for the choices they make and any actions they take. The person who has the problem is also the person who can solve it. People only change their behaviour when they feel ready to do so. The solutions people find for themselves are the most enduring and effective.
BOX 1 Stages of change model 1. Pre-contemplation stage (contented) The person sees many advantages in his or her current behaviour. The person has no interest in changing his or her behaviour. 2. Contemplation stage (considering change) The person thinks about the advantages and disadvantages of changing his or her behaviour. He or she acknowledges some dangers and risks. He or she still has many reasons for continuing current behaviour. 3. Preparation stage (acknowledging the benefits of change) The person realises that change is beneficial. He or she believes that change is possible to achieve. He or she makes plans to change. He or she takes steps towards change. 4. Action stage (making the change) The person changes his or her behaviour. 5. Maintenance (sustaining change) The person continues to implement the change. He or she copes without relapse. He or she deals with temptation. (Prochaska and DiClemente 1986)
BOX 2 Five general principles of motivational interviewing Seeking to understand the person’s frame of reference, particularly using reflective listening. Expressing acceptance and affirmation. Eliciting and selectively reinforcing the person’s self-motivational statements, expressions of problem recognition, concern, desire and intention to change, and ability to change. Monitoring the person’s readiness to change, and ensuring that resistance is not generated by jumping ahead of him or her. Affirming the person’s freedom of choice and self-direction. (Rollnick et al 2008)
Workshop programme The RCN Making Every Contact Count workshop combined theoretical presentations, group discussions, an explanation of how the techniques adopted from other therapies could be used to good effect in clinical practice, experiential learning, and practice through working together in pairs on a range of set tasks. The workshop was attended by staff from a variety of areas, including education, general nursing, practice nursing, community health, sexual health, occupational health, school nursing and health visiting. Six training events were carried out in 2013 across the UK. To achieve the aims of the workshop, participants were shown how to:
© NURSING STANDARD / RCN PUBLISHING
Use reflective listening skills to understand how the person perceives his or her issue or problem. Demonstrate acceptance and understanding of the situation. Clarify the presenting issue through open questions and reflection. Elicit and reinforce the person’s self-motivational statements. Listen for their understanding of a desire to change. Assess the person’s concerns, desires, intentions, and belief in his or her ability to change. Avoid generating resistance or arguments by pressuring the person to take action before he or she is ready. march 19 :: vol 28 no 29:: 2014 39
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Art & science behaviour change Affirm the person’s freedom of choice and self-responsibility to change. Recognise that a person’s readiness to change is often experienced as a fluctuating state of mind. Participants worked together in pairs to explore the limitations of asking closed questions and giving advice. The benefits of effective listening, asking open questions, clarifying people’s meanings and providing a summary of the conversation were demonstrated. For some participants this refreshed previous training on communication skills, but for most the information was new. Participants were encouraged to do further reading on the subject to develop their confidence in applying these techniques. A series of interactive experiential learning exercises enabled participants to practise listening, asking questions, reflection and clarification and summarising techniques.
Listening
Participants were asked to give the person space to talk and to practise listening without judgement, interruption, advice giving or making assumptions. The main teaching point of this exercise is that allowing a person to talk about the issue he or she wishes to discuss, from his or her perspective and without interruption, develops rapport (Rogers 1961).
Asking questions
Participants were asked to use simple open questions to encourage people to explain their situation in
BOX 3 Practitioners’ responses to challenging patient statements Patient: ‘I don’t think my diet is affecting my health, I’m eating less and I don’t feel better.’ Practitioner: ‘What made you decide to change your diet?’ ‘How did you do this? How did you hope to feel?’ ‘What have you heard about the problems of a poor diet?’ ‘Have you any concerns about what might happen to you if you don’t lose weight?’ ‘So you have some mixed feelings about your new diet?’ ‘What do you think is causing the problem?’ Patient: ‘Quitting smoking is much more difficult than I expected.’ Practitioner: ‘It sounds like you have been trying hard to make a change.’ ‘Why did you decide to stop?’ ‘What is the longest time you stopped for?’ ‘How did you manage this?’ ‘Are you using any medication to help?’ ‘What kind of support do you have?’ ‘Do you have any concerns about what might happen if you don’t stop?’
40 march 19 :: vol 28 no 29 :: 2014
their own words and from their perspective. The main teaching points of this exercise were that the way in which a question is posed can influence the quality and quantity of information provided. Some questions encourage the person to speak and others limit the amount of information offered (Rollnick et al 2008). Participants were encouraged to seek permission before providing advice because this helps the patient feel in control of the consultation. For example: ‘Would it be okay if I shared some strategies that have worked for others?’ (Miller and Rollnick 2010).
Reflection and clarification
Participants were asked to give feedback on the main points they had heard during the conversation exercises and include any non-verbal clues they had observed. On hearing the feedback, participants reported feeling valued and were surprised at the amount of information they had shared. The main teaching points of this exercise were: Providing feedback helps the person know you are listening and gives him or her an opportunity to reflect on the situation. People are more likely to share information when they feel heard and respected (Rollnick et al 2008).
Summarising
Participants were invited to discuss a change they wished to make. Their learning partners were asked only to use the techniques of listening, asking questions and providing a summary. They were instructed not to offer advice or suggestions. After this exercise, participants acknowledged that it felt good to be listened to and to be able to speak without interruption. They also recognised that they had the skills to identify their own solutions and that many patients could probably do the same with their support. The main teaching point of this exercise was that although it can take time and skill to help a person to identify a solution, a plan or idea he or she has thought of is more likely to be used (Rollnick et al 2008).
Applying the workshop techniques to practice The workshop participants were given the opportunity to address a range of situations where they might find patients’ responses challenging or frustrating.
Responding to challenging statements
To help participants apply their training to clinical practice, they were asked to respond to a series of challenging statements using open questions and reflection. The findings in Box 3
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show the effectiveness of the communication skills training exercises.
Responding to resistance to change
To address the frustration expressed commonly by staff when working with people who choose not to change, participants were shown how to work with people who they had described previously as ‘resistant to change’. The communication techniques recommended were to use open questions to identify what the problem means to the person and clarify his or her understanding of the risks posed to his or her health. Participants then worked in small groups to practise applying these techniques using role play scenarios. An example of how one participant implemented this exercise in clinical practice is shown in Box 4.
Post-course evaluation
Six Making Every Contact Count workshops were run in 2013 and further workshops may be available, depending on demand. The RCN nursing department conducted a post-workshop evaluation via email 12 weeks after each of the workshops. The survey found that the workshops had provided the majority of participants with practical examples of interviewing techniques and conversation starters.
These participants were able to ask patients different questions. Although this did not make the task of asking difficult questions easier, it did change the way participants approached this previously challenging area of work. Participants’ communication tactics now focused on using more encouraging, thoughtprovoking questions. The majority of the participants believed that the training had made it easier for them to have difficult conversations with patients.
Conclusion Increasing pressure on staff to address people’s poor lifestyle choices, and the frustrations they experience when they try to promote health, has left many nurses feeling frustrated and unconfident in this area of work. Providing staff with additional communication skills training can help address these problems and improve the motivation and confidence of nurses to undertake their role as providers of healthcare advice NS Acknowledgement The author would like to thank the Department of Health and Slimming World for providing sponsorship to support the RCN Making Every Contact Count workshops.
BOX 4 Participant’s case report after attending the Making Every Contact Count workshop ‘Prior to the RCN training I often felt frustrated when I saw a person’s health deteriorating because I knew it could be prevented easily if the person would amend his or her lifestyle. I saw my role in occupational health to provide information on staff current health status, any deterioration I had charted since their last visit, and to provide some facts/advice on the steps they needed to take to improve their health or fitness to fulfil the requirements of their role at work. I did not push and I thought my help was not needed if I was not asked. On follow-up visits I was anxious not to be confrontational, so avoided challenging any lack of action. Since the training, I understand that providing information is not enough to support a person to change their
behaviour and have adopted a partnership approach. I share my observations and concerns about my findings and give staff time to express their reaction to the results. Rather than telling them what they can do, I ask if they are happy for me to make some suggestions. I found this works well. I no longer feel like I am lecturing. Next, I ask about any concerns, fears or barriers they have about implementing the changes required. I explore what they think they can do differently, who might be able to support them and when they might start the changes. It has made a huge difference. The questions I ask now are different. Staff who previously said little, are now happy to set goals and talk through their plans with me.’
References McCance T, McCormack B, Dewing J (2011) An exploration of person-centredness in practice. Online Journal of Issues in Nursing. 16, 2, 1. Miller B, Rollnick S (2010) What’s New Since MI-2? www.motivationalinterview.org/ Documents/Miller-and-Rollnickjune6-pre-conference-workshop.pdf (Last accessed: February 26 2014.) National Institute for Health and Care Excellence (2008) Smoking
Cessation Services in Primary Care, Pharmacies, Local Authorities and Workplaces, Particularly for Manual Working Groups, Pregnant Women and Hard to Reach Communities. NICE Public Health Guidance 10. NICE, London. NHS Future Forum (2012) NHS Future Forum Summary Report: Second Phase Overarching Report. www.gov.uk/government/ publications/nhs-future-forum-
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recommendations-to-governmentsecond-phase (Last accessed: February 26 2014.) Prochaska JO, DiClemente CC (1986) Towards a comprehensive model of change. In Miller WR, Heather N (Eds) Treating Addictive Behaviors: Processes of Change. Plenum Press, New York NY, 3-27. Rogers CR (1961) On Becoming A Person: A Therapist’s View of
Psychotherapy. Houghton Mifflin, Boston MA. Rollnick S, Miller WR, Butler CC (2008) Motivational Interviewing in Health Care: Helping Patients Change Behavior. The Guilford Press, New York NY. Royal College of Nursing (2012) Going Upstream: Nursing’s Contribution to Public Health. Prevent, Promote and Protect. RCN, London.
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