Change Cycles

Richard de Ferrars

GP Faculty Frimley Park Hospital

Change Cycles

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

Change CyclesCan we do anything about “Not bovvered”?

Disclaimer – State the Obvious

• They way that people think and behave is totally unique

• Any model considering behaviour & changing it will be a simplification

• Does not mean that it is irrelevant!

Overview ScenarioScenario:

• You are in a consultation room with a patient who smokes 20 per day and has just been in hospital with their asthma

• In pairs, form a quick list of what you approaches you might take with them

• Summary from around the room

- generate a list

Motivation to Change

Dangerous assumptions:

People want to changePeople ought to changeThe time is right NOWTough approach works bestI’m the expert, they must follow my advice

The patient thinks & behaves in the same way that I do.....

What would work for us must work for them....

This person is motivated by xxx

Sticks and Carrots

• Which works best?• Which do we tend to use

most?

• Are there stick people and carrot people?

Stick People

Stick people worry about what might happen….

– best motivated by threat and worry

– Leave things to the last minute

– Tend to look at the negative aspects

Stick People

Why do we select sticks?

– We are a stick person?– We assume that the patient is

a stick person?– We think it has most impact?

Carrot Man

• Carrot man looks at what could happen….

– Positive outlook

– Looks for opportunity

– Well-prepared

Carrot Man

Why might we select carrots?

– We are a carrot person?– We assume that the patient is a

carrot person?– We think it has motivates best?

Sticks & Carrots

Stick man worries about what might happen….

– best motivated by threat and worry

– leaves things to the last minute

– tends to look at the negative aspects

Carrot man looks at what can happen….

– positive outlook

– looks for opportunity

– well-prepared

Straw poll – stick or carrot?

Overview Scenario

Scenario:

• You are in a consultation room with a patient who smokes 20 per day and has just been in hospital with their asthma

• In pairs, form a quick list of what you approaches you might take with them

• Have you selected sticks or carrots?

• Look at the list and assign “stick” or “carrot”

The Theoretical Bit

Two theories/ models:

• Health Belief Model

Rosenstock 1966

• Transtheoretical Change Model

Prochaska et al 1994

Health Belief Model

Perceived susceptibility & seriousness of

disease

Perceived threat of disease

Likelihood of change

Cues to Action:

•education

•information

Personal Factors:

•age, sex, ethnicity

•socio-economic factors

•knowledge

What factors influence this perceived threat?

What then is our role?

Transtheoretical Change Model

Sounds very complex…..

Is in fact very simple

Five stages of change

Precontemplation

Ignorance is bliss:

Individual has not considered adopting the behaviour

Contemplation

Considering adopting the

behaviour but not taken

any positive action

Preparation

Individual has started to

collect information

and resources with a

view to enacting the

change

Action

Individual has started to

enact the behaviour

but not yet continued

over a long period

Maintenance

The behaviour has been

regularly enacted for

more than 6 months

Change CyclesPrecontemplation

Contemplation

Preparation

Action

Maintenance

Our job is to energise this sequenceIdentify which stage the person is at

Identify sticks/ carrots, support, services…. that could move them onto the next stage

Back to the list....

Go back to our list of

interventions

Which stage are they working on?

Pick sticks & carrots that you

could use at each stage

Gaps? (eg no carrots at stage 1),

think of how to fill the gaps

1. Precontemplation

2. Contemplation

3. Preparation

4. Action

5. Maintenance

Motivational Interviewing

What is it?

A client-centred, semi-directive method of engaging intrinsic motivation to change behaviour by developing discrepancy and exploring/ resolving ambivalence within the client.

In my words – trying to make sure that it is the patient who will do the hard-work

Motivational Interviewing

Grid for Assessing Motivation:

Advantages Disadvantages

No Change

Change

Scoring motivation:

1. Importance of making a change (score 1-10)

2. Confidence of making a change (score 1-10)

In pairs:

Try this out imaging you are an ES talking to their trainee about learning log entries….

Motivational InterviewingThe Four A’sAsk Raise issues in a non-confrontational way Assess motivation (1-10 importance & confidence)

Advise Use the grid so that patient gives themselves the advice

Highlight contradictions“You say you smoke to help your nerves, but you also say

that you worry about the effect of smoking on your health?”

Assist Elicit change talkElicit self-motivating strategies

“When I asked about motivation, why did you not score 0?”

Arrange Follow-upEnd positively – “Can always come back if needed”Roll with resistance – accept the patient’s outcomeNot stick man’s approach?

How Can I Help My Patient?

MI Tools• Importance & Confidence

(1-10 score)• Change grid

MI Fours A’s• Ask & assess motivation• Advise – change grid• Assist – elicit change talk• Arrange follow-up

– End positively, roll with resistance

• Think carefully about sticks and carrots

• Think about influencing the “perceived threat”

• Think about the stage of the change cycle

The End