Change Is In the Air

"CHANGE IS IN THE AIR: US, ME AND THE PATIENTS"

'''RATIONALE'''

To illustrate the common threads across three scenarios for behaviour change: the service system, ourselves and our patients. To help participants to identify with how patients feel. To open up the question of how best to encourage people to change. To introduce key concepts like readiness, ambivalence and change talk in a naturally unfolding manner, linked to their own experience of anticipated change. The exercise might work best in a group who all come from the same setting?

'''FORMAT'''

Combination of mini-"lectures", small group discussion, large group elicitation. One effectively uses a guiding style to elicit answers to key questions. This can take anything from 30 min to 1.5 hours, depending on how interactive you want it to be, and how much depth you want to go into.

'''PROCEDURE'''

Use an unfolding table in powerpoint or on the blackboard, with three rows for the scenarios ("Us", "Me" and "The Patient"); and two columns for " the scenario", "the challenge". One can vary the column headings quite a lot. The row headings are fixed.

'''1. Introduce the task'''

"We will be looking at invitations to change behaviour in three situations, starting with your service, then turn to ourselves personally, and finally to our patients. At each level I will be giving you a scenario, and then we will examine how we all feel about them, what the key challenges are and how we might overcome them."

'''2. Present Scenario 1: Change in the system'''

Provide the scenario "The Dept of Health (or professional body or management in hospital or service) has decided to introduce a new Patient Personal Plan system into every service, designed to ensure patient involvement in care and improve consistency of record keeping. You knew this was coming. Colleagues have been talking about it for months, some positively, others less so, and you've noticed reports in the press. It seems like your behaviour needs to change, everyone's! I want to know how you are feeling about this"

Discuss

Can be done in pairs, small groups, or large group. I used three questions:

a. How do you feel (ambivalent is a common outcome!)

b. How could this change be botched up?

c. How could it be introduced with you on board?

Large group debrief well worth it. When with large group, do the facilitation of their experience in the present tense. Say things like, "..so you are feeling angry with management because, ...".

Its possible to make a number of links and to illustrate a number of concepts and lessons for change implementation in a large group debrief. In fact, if you use reflective listening while doing this, you'll notice that you can elicit sustain talk and change talk quite easily!

· Ambivalence and readiness: here is a sample of reflective listening statements I made that captured their feelings. "So you feel quite unsure about this change...". "So most of you feel unsure about the change"; "Aha, so you feel very annoyed and will definitely resist this change"; "You feel really committed to it...". This allowed me to draw a readiness to change line on the board, and we found that most were in the usual 4-7 out of 10 range......in fact we drew up a normally distributed curve above the line. When I asked them for one word to describe how the majority in the middle felt, the word ambivalence came right out.

· Change talk & sustain talk: I asked someone to repeat what they had just said ("I want to help this change happen"), wrote it on the board, and gave it the change talk label. Same for sustain talk.

· Facilitating or undermining change: A simple open question about what might facilitate or hinder change and their commitment to it elicited a host of conclusions, each of which I wrote up on the board: "A heavy-handed top-down approach makes me angry"; "I want to be listened to, and involved in the process", and so on.

'''3. Present Scenario 2: Change in us'''

Provide the scenario "You attend a consultation with your primary care practitioner and it emerges that your cholesterol is very high, and you get the feeling that you are obliged to change your diet, get more regular exercise, drink less alcohol, and if you smoke, to quite right away".

Discuss

Can be done in pairs, small groups, or large group. I used the same three questions as for scenario 1:

a. How do you feel?

b. How could this effort to encourage you to change be botched up?

c. How could it be introduced with you on board?

Again, do the facilitation of their experience in the present tense. "So you are feeling a bit bewildered...." The key points that emerge bear a striking resemblance to those for scenario 1. In fact, I hardly needed to write down anything new on the board. Words like "overwhelmed" were the most frequently used characterisations of the way they felt.

A useful strategy was for me give voice to the dilemma of the busy practitioner in this scenario. "I am this practitioner. Now tell me, what can I do? These are the facts, I am giving them to you nicely and clearly, and I don't have time to go into this with you in detail right now". One participant at the back got so "annoyed" that she said, not altogether seriously, "well if you don't have time to talk with me like a human being then leave your job"!

'''4. Present scenario 3: Change in a patient'''

Provide the scenario "A typical case of a patient who is required to change". If they are from the same setting, you can construct this beforehand having spoken to a few of them about the profile of a typical patient.

Discuss
Can be done in pairs, small groups, or large group. I used the same three questions as above, with the same outcome!

'''THE NEXT STEP?'''
I found it easy to anticipate going in any of a number of directions after this exercise. I turned to the question of how best to facilitate or hinder constructive talk about change with patients, and I went through the three communication styles. I anchored this presentation in the second scenario above, asking them how they would feel if the practitioner used each of the three styles. They came up with a preference for a guiding style!

by Steve Rollnick