Practitioner Development Programme

Skills Workshop 1

Welcome and Introductions

• Tutors• All in group• Name and area of work• House keeping;

-Manage self

- All teach all learn

-Toilets

-Fire alarm & exits

-Refreshments

-Mobile phones

Successes & Challenges

• Share your experiences of signposting people with long term conditions to the SMP

• Share your experience of the Self Management Questionnaire

• Share update action plan activating intervention

Aims Skills Workshop 1

During this workshop you will have the opportunity to explore the skills which contribute to successful collaborative agenda setting including;

• Building the relationship & rapport• Establishing an empathic relationship• Co-producing the agenda• Eliciting the patient’s priority and expectation• Clarifying & negotiating boundaries for the consultation

You will also have the opportunity to consider how your team and services work and how these processes impact your ability to successfully support patients to self manage and identify ideas you have to overcome barriers

Programme aim – review

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Achieving improvement

by changing relationships

between people & health services

The nature of the interaction

created by the structures, processes and

behaviours that exist within the system

Patients, clients groups, service users, carers,

families and communitiesBoth the people who work in and deliver care services and

the wider system

Safe, effective, timely, person centred, equitable

and efficient

Co-creating Health.What are we trying to achieve?

Our aim is to support people with long term conditions to develop the knowledge, skills and confidence to manage their own health and healthcare (to become activated).

Co-creating Health supports people with long term conditions on their journey of activation

Compared with people at low levels of activation, people at high levels of activation tend to live a higher quality of life, have better clinical outcomes and make more informed decisions about accessing medical services.

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Levels of activation

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The CCH Integrated Model

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©The Health Foundation

Health behaviour modelling

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Biological

Social / BehaviouralEmotions / Thoughts

Learning agenda

• Share something that is working well for you in supporting people who live with LTC’s to self manage

• Share something that you find challenging/frustrating

• Record on flip chart

• Review list end of skills workshop 3

• Consider how the skills we cover can support you to find solutions to your challenges

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Agenda setting– Identifying issues and problems

– Preparing in advance

– Agreeing a joint agenda

Goal setting– Small and achievable goals

– Builds confidence and momentum

Goal follow-up– Proactive – instigated by the system

– Soon – within 14 days

– Encouragement and reinforcement

– Most challenging to achieve

– Key for maintenance & progress

Becoming an active partner

Making change

Maintaining change

Three key Enablers for clinicians, patients & systems

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The CCH Integrated Skills Model

E

©The Health Foundation

Agenda setting

Goal setting & Action Planning

Goal follow - up

Exploration

PlanningProblem solving

Traditional v collaborative•Information & skills are taught based on clinician agenda

•There is a belief that knowledge creates behaviour change

•The patient believes it is the clinicians role to improve health

•Goals are set by the clinician and success is measured by them

•Decisions are made by the clinician

•Patient & clinician share their agendas and collaboratively decide what information and skills are taught

•There is a belief that one’s confidence in the ability to change, together with skills and knowledge creates behaviour change

•The patient believes that they have an active role to play in changing their own behaviours and improve their own health

•The patient is supported by the clinician in defining their own goals & success is measured by their ability to attain those goals

•Decisions are made as a patient-clinician partnership

Successful Co-Creation requires:

Exploration

Inviting patients to contribute their beliefs, knowledge and values that are critical to co-creating a partnership approach to their health and well-being

Supporting patients to explore their ambivalence and explore decisional balance

Using exploratory skills to find out what is important to the patient rather than considering what is important for the patient

Successful Co-Creation requires:Planning

Clinicians and patients collaborating on goals of treatment and the action steps that each will pursue to build health, well-being and confidence

Exploring levels of importance and confidence

Supporting autonomy and choice

Exploring what will support this process and what challenges and barriers might get in the way

Agreeing how and when to follow up

Successful Co-Creation requires:Follow-up

Patient and clinician supporting self-management by arranging to learn from the results of the action plan within a meaningful, proactive timeframe and agree next actions.

Phase 1 experience has shown that timely follow up (preferably within two weeks) is essential if patients are to continue to translate intention into action, implement action plans, achieve goals and become more successful confident self managers.

Current systems and economics require us to find creative and sustainable solutions to these challenges.

Successful co-production requires:

Problem solving

Clinician and patient explore the challenges to self- management and collaboratively identify possible solutions.

Clinician coaches patient to develop problem solving skills and confidence for self-management.

Patients identify the support and services they need to achieve their goals.

Organisations and systems develop/amend processes to support successful SM and SMS.

The three roles

• Teacher - information & education• Manager - acute & emergency• Coach – collaboration, partnership, confidence

• We need a full‘tool kit’ of skills

• All roles have a place and a value

• We need to be confident to move in and out of the roles

• We need to consider the these roles in the context of our professional responsibility, job satisfaction and self esteem

Skills list

•Reflection/Empathy

•Explore agenda/priority

•Explore agenda: clarify boundaries

•Explore beliefs about self-management

•Explore importance 0-10

•Explore confidence 0-10

•Support autonomy & choice

•Double-sided reflection

•Explore ambivalence

•Invite goals

•Ask before advise

•Problem solving

•Action planning

•Effective Follow-up

Learning & understanding the patient perspective

• Exploring the patient’s perspective is very powerful• It helps build a strong relationship and rapport• It enables us to gather excellent information• It allows us to make efficient use of the time • Key skills that support us to do this are;

-Open-ended questions- Affirmation, normalisation-Reflection-Empathy

Open-ended questionsQuestions that cannot ne answered with a ‘yes or no’They invite a broader responseThey create a more equal conversation

-How…? -Where…?-What…? -Who…?-When…? -Tell me…?

Avoid

Why…? Can be risky, it can make the individual feel defensive and that they have to justify their answer

Affirmations, normalisation

Affirmations:

Look out for ‘change talk’ in patient story and affirm (‘you told me you tried to change before- that shows great determination’)

Normalisation:

Helps patients feel validated, that they are not alone, and that the practitioner has experience of working with people like them

‘Many people tell me a similar story’‘Its natural to feel the way you do’

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Reflective listening

Using words to let the person know that you have heard what the they have said or to check facts;

• So, you are saying…• It sounds like…• You were wondering if…• I hear you saying…

Non verbal body language is not enough

Empathy

Using words to let the person know that you understand or are trying to understand how it feels for them emotionally

• Reflection … You seem [frustrated, worried, sad]

• Validation…Anyone would feel

• Partnership…I’d like to help

• Respect…I’m impressed by how you

Listening to change exercise• Think of a change you are considering

• Groups of 3

• Interviewer, Observer, Interviewee

• Explore using (only) OEQ’s, reflection & empathy

• Switch roles

• Group debrief

Treat with care• Never underestimate the value of empathy & reflection

• It’s the what we lose when we are busy, stressed or distracted

• It delivers a value to the patient and clinician and their relationship over and above the basic exchange of information

• As we start in our working lives we often have a more human gaze – as our knowledge and experience increase we adopt a more medical gaze – as we realise the complexities of life and illness and the difficulties people face with regard to health behaviour change we seek to redress that balance

Co-producing the agenda

Use open ended questions, reflection and empathy to explore everything that the patient wishes to cover in the consultation, find out their priority and what they are hoping will happen (allow time for their response)

• What would you like to talk about today? [avoid temptation to use ‘how can I help you?, what can I do for you?’]

• So you have been feeling more tired and you have been coughing more... Is there something/anything else?

• Give the patient the opportunity to share all their issues ?

• Use summary reflection to pull together

• ‘Out of those things which do you feel is your priority?’

• ‘What were you hoping would happen/we would achieve today?’

Co-producing the agenda

• Gather this overview before funnelling down to detailed information gathering

• Avoid the temptation to explore the chief presenting complaint before eliciting all the agenda

• Do not fear ‘the list’• The process is efficient and can be successfully utilised

within the time frames for a primary care consultation• Helps minimise the late addition to the agenda ‘Oh by the

way’ , ‘whilst I’m here’• Can be applied to all clinician:patient interactions

Co-producing the agenda

• Once you know patient agenda, priority, expectation • Recognise & share clinician agenda, priority, expectation,

inviting patients to acknowledge clinicians responsibility

• From my perspective the things we need to cover today are.....is that OK?

• Other things I think it would be helpful for us to discuss are....is that OK?

• I have some information regarding your test results that I would like to share......is that OK?

Negotiating & clarifying boundaries• When both agendas are known it is possible to negotiate and agree what is

to be covered in the consultation and to give just attention to other agenda items at a later time or in a different way

• If medical agenda truly supercedes patient priority due to clinical risk, use collaborative language to explain and negotiate

• Share your perspective and rationale

• Find common ground before proceeding

• Use language of focus, patient’s self interest

Empathic Bridge

A useful tool for refocusing if the consultation goes off track

• You need to know agenda, priority, expectation• Use the patient’s language• Link with And.....• Underpin with empathy• Back on track.....

Try to avoid using ‘But’ in this or any other situation‘But’ negates all that has gone before Consider your own response to statements that contain ‘but’

Example

I’m really sorry to hear you have had such a stressful time it sounds as if it has been really tough for you.......

And..... I know you wanted us to cover your leg pain, your sleepless nights and your increasing breathlessness....

And......That your breathlessness is your main concern and you wanted to know if your heart is coping.......

So.... Is it OK if we focus on examining your chest......

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Beware?!

• All the skills; whose agenda?

• Collaborative agenda setting is the foundation for successful goal setting

• Why might goal setting fail?

• What is important to the patient as well as what is important for the patient

Examples of Activating interventions

•Results in advance•Agenda setting sheets•Patient held record•Access to information•Information sharing•Patients attending SMP skills training

•What do we need to change in the way we work that will support collaborative agenda setting and how might we do this?

Experiential practice

• Consider the skills we have covered and decide what you would like to try

• Most useful to select an area for which you attach high importance and have low confidence

• Safe environment to try things in a different way and seeing what happens

Action plan & next steps

The skill I am going to work on; (e.g. from the skills descriptor list)

The patient focused activity I am going to work on; (e.g. finding out about patient education & support groups, testing support tools such as the confidence ruler)

The process I am going to work on; (e.g. trialling agenda setting sheets, sending out test results in advance )