Having Motivational Lifestyle Conversations by Health Diagnostics

Having Motivational Lifestyle Conversations

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Health Diagnostics Ltd Chatham House Dee Hills Park Chester CH3 5AR Phone: 01244 311811 Email: info@healthdiagnostics.co.uk Twitter: www.twitter.com/healthdiagsltd www.healthdiagnostics.co.uk

A workbook providing guidance on using Motivational Interviewing techniques during a NHS Health Check. Intended to offer practitioners advice on how to have constructive conversations that encourage positive lifestyle change.

Introduction The emphasis is to bring out an individual’s inner motivation to positively change their lifestyle.3 As will be demonstrated, this can be achieved through a combination of open questions, affirmations, reflections and summaries (OARS).4 Many of these techniques are used in professional counselling however our aim here is to make them accessible and relevant to the circumstances offered during the NHS Health Check. Due to the specific conditions available during the health check, an information exchange on the health implications of certain behaviour, alongside tips of how an individual could possibly make lifestyle change, feature as a part of the brief intervention.

Having Motivational Lifestyle Conversations Introduction During a NHS Health Check, individuals will often be open to the idea of discussing their health and the future implications that changes to their lifestyle may have. These discussions are most necessary in cases of high and medium cardiovascular risk. The visual tools available in Health Options® (such as the risk graphic and ‘what if’ scenario) can be used to great effect in conjunction with the conversational techniques outlined in this document. A hypothetical step-by-step walkthrough is covered over the next few pages. Always be aware however of the need to be ﬂexible in your approach and react to whatever individual circumstances you encounter.

During this document, smoking will be used as an example. However, the conversational techniques shown in this motivational interview can be used and applied regardless of the health issue under discussion. What is said and the information you offer will obviously differ if you’re discussing smoking as opposed to a healthy diet, for example. However, how you say it, the kind of questions you ask and the general approach will remain similar. Crucially, the principles and structure may remain consistent. The content of the conversation however is dependent on listening to the client’s priorities and facilitating a discussion that is relevant to those concerns.

Humility2

Partnership/ Fundamentally, motivational Collaboration interviewing comes down to ‘intuitive helpfulness’.1 According to MI-3, the essential principles of Acceptance motivational interviewing are: (Absolute Worth, Compassion

Autonomy, Accurate Empathy, Afﬁrmation)

Evocation (evoking the client’s thoughts and feelings)

Respectful curiosity

1 Jeff Allison, 2013, Intermediate-Advanced MI workshop, What is MI?, 18.02.2013, Cardiff 2 Allison, What is MI?, 18.02.2013, Cardiff 3 Tom Barth, 2013, Intermediate-Advanced MI workshop, Motivational Interviewing, 18.02.2013, Cardiff 4 Barth, Motivational Interviewing, 18.02.2013, Cardiff

Humility2

Autonomy, Accurate Empathy, Afﬁrmation)

Evocation (evoking the client’s thoughts and feelings)

Respectful curiosity

Your Approach

Approaching the Conversation Engagement with the client is crucial to the effective communication of risk. This should be achieved throughout the course of the consultation by adopting a friendly, non-judgemental, ‘bed-side’ manner. The importance of polite basics such as maintaining eye contact and demonstrating respectful curiosity cannot be underestimated. If done effectively, by the time the CVD risk conversation comes around (after 15 minutes or so), the client should be comfortable with the idea of talking openly about the potential for lifestyle change. A crucial factor in conducting a successful brief intervention is to listen attentively and focus on issues that are the client’s own priorities, (as opposed to being those of the practitioner). Essentially, it is vital to work within the context of the client and their life. So, given all the results (some of which will be better than others), a good open question to ask may be something like: 3

‘Given what you’ve learnt about your health status, which of these individual results are most important to you and your health?’

A good time to ask this question is after you’ve shown the client their current risk score but before you’ve shown them any ‘what if’ results. The client may then, for example, say that looking at their smoking is something that they feel is important. This effort to focus on one lifestyle change at a time and take ‘baby steps’ rather than giant leaps, is an important way of improving the chances of success. Given the person states that smoking, for example, is an important lifestyle issue, the next thing is to establish if the person is comfortable with talking about their habit:

‘Do you mind if we discuss your smoking?’

Assuming that the client says they’re comfortable to discuss the lifestyle issue, (and they are likely to be more inclined to do so if a non-judgemental attitude has been adopted throughout the consultation), the next step may be to ask an open question such as:

‘So can you tell me how you feel about your smoking?’

Your Approach

‘Given what you’ve learnt about your health status, which of these individual results are most important to you and your health?’

‘Do you mind if we discuss your smoking?’

‘So can you tell me how you feel about your smoking?’

Conversation Type 1

‘Yes, I mean, I’ve got a little boy and I don’t smoke around him but it can’t be good for him seeing his mum smoke can it?’

Having the Conversation Give the client chance to speak and listen carefully to the response. ‘Reflecting’ what the client says and repeating what they say (albeit by perhaps changing the phrasing slightly) is a simple way to demonstrate attentive engagement. See below a brief example of how this might work and sound in practice:

‘Well I know it’s not good for me and I have tried to quit before’

‘Definitely, but I’ve found quitting impossible in the past’ ‘It wouldn’t be easy’ ‘No, but I think I could give it another go’ ‘So you’re aware of some of the negative health impacts and the effects that smoking around your little boy might be having and what’s more, it sounds like you’re ready to try again to quit.

‘So can you tell me how you feel about your smoking?’

‘OK, so it sounds like it’s important to you and something that you’re already conscious of.’

‘You’re concerned about the effect this could have on your child as well the effects it is having on your own health.’

You’ll notice that comments that come from the practitioner begin with an open question which invites the client to speak without leading them into a particular response. From then on, it’s predominantly a case of listening to what the client has to say about the issue and reﬂecting their thoughts and feelings back at them in an engaged and empathetic manner. The ﬁnal

comment from the practitioner in this sequence acts as a brief summary of what has been said thus far. Most conversations are unlikely to be as straight forward as the above example, however many of the conversational techniques remain the same. Please see example on following page:

Conversation Type 1

‘Yes, I mean, I’ve got a little boy and I don’t smoke around him but it can’t be good for him seeing his mum smoke can it?’

‘Well I know it’s not good for me and I have tried to quit before’

‘So can you tell me how you feel about your smoking?’

‘OK, so it sounds like it’s important to you and something that you’re already conscious of.’

‘You’re concerned about the effect this could have on your child as well the effects it is having on your own health.’

Conversation Type 2

‘It is and it has been for a long time.’ ‘It sounds like you’ve perhaps fallen into a routine of smoking when you’re around certain people. Tell me, can you imagine yourself going out and not having a cigarette?

‘So can you tell me how you feel about your smoking?’ ‘Well I don’t smoke that much. I suppose I’m on about 10-15 per day. It’s something I enjoy but I suppose I know it’s not great for my health.’ ‘OK, so you’re currently smoking around half, to three quarters of a pack a day and you’re aware that this might be having some impacts on your health. ‘Yes, well obviously it’s not good for me but there are lots of things that could damage my body. Plus, it’s a social thing for me. Lots of my friends do it. ‘I see, so smoking is a part of how you interact socially when you’re around other people who are smoking.

‘Well I can imagine it, yes. It could be nice actually. My clothes wouldn’t smell... neither would my breath! ‘OK, so you can see some advantages to not smoking in that, despite your friends doing it, you wouldn’t smell of tobacco and would gain other health benefits.’ ‘Yes, there would definitely be advantages to quitting...’

The above conversation does not lead to quite the same conclusive change talk as the first conversation. However the practitioner does at least cause the client to consider what the advantages of changing their behaviour may be. Again, this is brought about predominantly through open questions, repetitions and affirmative summaries.

Conversation Type 2

Open Questions & Refelections

In terms of reflecting, the following sentence could allow for the practitioner to reflect back any number of the subsequently listed possibilities: ‘I probably have to do something about this problem’

Open questions should function as an invite for the client to speak. The following are some examples of how these may sound during the consultation: ‘How come you’re thinking about making this change?’

‘How important is it to you to make this change now?’

‘...Do something...’

‘...Problem...’

‘You’re looking for some advice’

‘You’re looking to make a change’ ‘How would you do it if you decided to?’5 ‘You’ve made a decision’

‘So you’re really concerned’6

5 Barth, Motivational Interviewing, 18.02.2013, Cardiff 6 Barth, Motivational Interviewing, 18.02.2013, Cardiff

Open Questions & Refelections

‘How important is it to you to make this change now?’

‘...Do something...’

‘...Problem...’

‘You’re looking for some advice’

‘You’re looking to make a change’ ‘How would you do it if you decided to?’5 ‘You’ve made a decision’

‘So you’re really concerned’6

5 Barth, Motivational Interviewing, 18.02.2013, Cardiff 6 Barth, Motivational Interviewing, 18.02.2013, Cardiff

Visual Scale

Because the goal of the practitioner is to try to elicit and strengthen the voice inside the client that is positive towards the idea of lifestyle change, when giving summaries the practitioner

should look to place the emphasis on the change talk (as opposed to the resistant ‘sustain talk’ that may be in favour of continuing with the behaviour). Good phrases with which to begin a summary may be:

‘So what you’re saying is...’

‘Let me just check if I’ve understood everything correctly...’

Asking questions such as this can allow the practitioner to get a handle on how the individual feels about the health issue and how informed they are of the associated risks. It may also be a good marker to revisit at the end of the brief consultation in order to establish whether the information given has caused any change in the client’s perception of the health behaviour.

That said, the exchange of accurate and relevant information on how health behaviours may be affecting a person’s health is also an important part of the NHS Health Check. Finding the right balance by exploring what is important to the client and offering them the tools that they need, can prove a positive way of marrying these intervention requirements.

The simple techniques brieﬂy demonstrated above are intended to increase the client’s autonomy, an important process in encouraging behaviour change. The assumption behind placing the emphasis on the client’s autonomy is based on the belief that people are better convinced by their own arguments, as opposed to those imposed by others.

The next stage in the conversation may therefore involve an information exchange. In order to maximise the opportunity, the visual impact offered by the Health Options® cardiovascular risk calculator can be deployed at this point. We’ll continue on with the smoking example outlined above:

‘Can I ask, what kind of effect do you think quitting or cutting down may have on your cardiovascular risk?

Another commonly used tool is the numeric scale. Practitioners may find it useful to ask the client where on a scale of 1-10 they feel they’d place their level of importance:

1 2 3 4 5 6 7 8 9 10

I presume it might drop me down slightly? That is normally the case. I can actually use the software to show you on this graph where your risk level would be if you were to cut out the cigarettes. Oh right. That would be interesting to see.

Visual Scale

Because the goal of the practitioner is to try to elicit and strengthen the voice inside the client that is positive towards the idea of lifestyle change, when giving summaries the practitioner

‘So what you’re saying is...’

‘Let me just check if I’ve understood everything correctly...’

‘Can I ask, what kind of effect do you think quitting or cutting down may have on your cardiovascular risk?

Another commonly used tool is the numeric scale. Practitioners may find it useful to ask the client where on a scale of 1-10 they feel they’d place their level of importance:

1 2 3 4 5 6 7 8 9 10

Risk Graphic

Smoking will generally have the effect of doubling a person’s cardiovascular risk. Using the risk graphic as a visual aid, the practitioner is able to demonstrate how lifestyle change could potentially have a significant impact on the client’s cardiovascular risk.

This can prove to be a powerful motivational tool when used in conjunction with an engaged and non-judgemental manner that constantly afﬁrms the client’s right to choose. In granting this autonomy, the practitioner reinforces the fact that it is the client and only the client that is responsible and ultimately answerable to the state of their own health. To visualise this idea, clients may ﬁnd it useful to think of their future selves as a person who is dependent on them and their lifestyle choices in the here and now.7

As mentioned, the conversation could follow a similar course if the issue under discussion was exercise or eating habits for example.

By modifying cholesterol and blood pressure readings in the software’s ‘what if’ scenario – both of which are likely improve if the client actively changes their health behaviour - the practitioner is able to demonstrate the effect of lifestyle change, whatever the client’s priorities may be.

7 David H. Freedman, 2013, ‘Time-Warping Temptations’ in Scientiﬁc American Mind, March-April 2013, p.49

Risk Graphic

As mentioned, the conversation could follow a similar course if the issue under discussion was exercise or eating habits for example.

7 David H. Freedman, 2013, ‘Time-Warping Temptations’ in Scientiﬁc American Mind, March-April 2013, p.49

Establishing what the client already knows by listening closely to the information they provide you with will allow for the intervention to be as targeted as possible. As already mentioned, ﬂexibility and ﬂuidity in the way that the practitioner approaches the conversation will help enormously in facilitating a valuable brief intervention.

Once you’ve provided the client with the information, you may wish to ask them something like:

‘Does that change how you feel at all?’

Assuming that the client is interested in planning a change, use the lifestyle top tips cards to offer the individual advice on simple changes they could look to make to their daily routine. The practitioner should also use this opportunity to signpost the client to appropriate local services, eg. smoking cessation.

OR ‘What do you think could be the next step?’

“10

Top Tips fo

Diabetes Risk

. Aim for enough sleep Ensure you get minimum. per night as a

breakfast, good al with a healthy leme Start the day beans on who t be porridge, choices migh eggs. or scrambled toast, poached may cause your energy drinks and erate tea e, mod y so Coffe to fluctuate wildl energy levels your intake. ry drinks and on sweet, suga gy. Avoid snacking quickly release their ener that refined foods

“ 10

Top Tips for

Keep active, any

Physical Activity

ly fruit that slow s, nuts and dried Snack on seed gy. ener release their of moderately Aim to build up to 30 minutes minutes Short 10 intense activity per day. ry if you are in a sedenta sessions all add up and up and walk around job, make sure you get at least every hour. Use stairs instead of lifts

old tasks and chores

Complete everyday househ with vigour.

and escalators.

“ 10

s. ed ‘cycle to work’ scheme Enquire about subsidis Many employers run these.

Top Tips for

‘Does what you’ve learnt alter where you’d place the issue on the 1-10 importance scale?’

Giving myself a break from screens in the evening after spending all day at a desk helps me get a better night’s sleep

Top Tips for

Sleep Health

Frequent exercise and a regular sleep pattern seem to go hand in hand

Healthy Eating

te, walking Be active on your commu possible. and cycling whenever

a stop earlier and park Get off the bus or train supermarket. further away from the

of 5 portions of fruit and Aim to eat a minimum for a ‘rainbow’ of colours vegetables per day. Aim on the plate.

My workplace productivity improves drastically when I’m sleeping well

the week will allow Planning your meals for ically. you to shop more econom Home prepare healthy for work.

Enquire about showering space in your workplace.

facilities and locker

er has a subsidised gym Ask whether your employ a sports and recreation membership scheme or check out your local club. And don’t forget to can often be used on a authority services which pay per use basis. Don’t go food shopping

when you’re hungry.

Try to eat at least 2 portions 1 should be oily.

of fish per week,

out for high levels Read food labels and watch may be shown as of salt, fat and sugar. These labelling system used ‘red’ on the traffic light by many manufacturers.

snacks and lunches

healthy soups and don’t Use a blender to make over cook the vegetables. lemon juice instead of Use herbs, spices and food. to add taste to blander

ficial.

exercise is bene

release ins that help aining B vitam might be lean Eat foods cont . Good sources energy from food poultry, low fat diary products and cuts of meat als. in cere and wholegra ability reduces your much alcohol with Consuming too is it fattening gy. So not only store more fat. to make ener it helps the body empty calories,

r, carry Be prepared for bad weathe shoes that are an umbrella and wear reasonable comfortable to walk a distance in.

club or fitness class. Look into joining a sports can make Exercising with others n and enjoyable. it a more social occasio

I feel so much more energised and less sluggish since I started focussing on getting good sleep

se s hormones relea pressure, stres energy levels. Manage your s and lows in fuel causing high water per day. (8 glasses) of pints 4 Aim to drink

7 hours

“

These should provide the practitioner with adequate knowledge to be able to inform the client that, for example, if they want to improve their HDL readings, increasing the amount they exercise is likely to be most beneﬁcial.

‘Where can you go from here?’

“

In order to develop knowledge of how individual measurements are affected by certain health behaviours, consult the operator’s manual and pop-up help screens available in Health Options®.

The individual may acknowledge that learning about their risk has changed their perception. If so, they may also be inspired to ﬁnd out more in regard to how they can go about making some practical lifestyle changes. In such instances, the practitioner may wish to ask something like:

“

Tools to Help

salt

foods such as white Avoid processed and refined rice. Replace these white breads, white pasta and brown variety. with the wholemeal and and burgers with lean Replace fatty sausages of meat. An imitation meat poultry and leaner cuts fat alternative to meat. such as quorn is a how

7 David H. Freedman, 2013, ‘Time-Warping Temptations’ in Scientiﬁc American Mind, March-April 2013, p.49

Once you’ve provided the client with the information, you may wish to ask them something like:

‘Does that change how you feel at all?’

OR ‘What do you think could be the next step?’

“10

Top Tips fo

Diabetes Risk

. Aim for enough sleep Ensure you get minimum. per night as a

“ 10

Top Tips for

Keep active, any

Physical Activity

old tasks and chores

Complete everyday househ with vigour.

and escalators.

“ 10

s. ed ‘cycle to work’ scheme Enquire about subsidis Many employers run these.

Top Tips for

‘Does what you’ve learnt alter where you’d place the issue on the 1-10 importance scale?’

Giving myself a break from screens in the evening after spending all day at a desk helps me get a better night’s sleep

Top Tips for

Sleep Health

Frequent exercise and a regular sleep pattern seem to go hand in hand

Healthy Eating

te, walking Be active on your commu possible. and cycling whenever

a stop earlier and park Get off the bus or train supermarket. further away from the

of 5 portions of fruit and Aim to eat a minimum for a ‘rainbow’ of colours vegetables per day. Aim on the plate.

My workplace productivity improves drastically when I’m sleeping well

the week will allow Planning your meals for ically. you to shop more econom Home prepare healthy for work.

Enquire about showering space in your workplace.

facilities and locker

when you’re hungry.

Try to eat at least 2 portions 1 should be oily.

of fish per week,

out for high levels Read food labels and watch may be shown as of salt, fat and sugar. These labelling system used ‘red’ on the traffic light by many manufacturers.

snacks and lunches

healthy soups and don’t Use a blender to make over cook the vegetables. lemon juice instead of Use herbs, spices and food. to add taste to blander

ficial.

exercise is bene

r, carry Be prepared for bad weathe shoes that are an umbrella and wear reasonable comfortable to walk a distance in.

club or fitness class. Look into joining a sports can make Exercising with others n and enjoyable. it a more social occasio

I feel so much more energised and less sluggish since I started focussing on getting good sleep

se s hormones relea pressure, stres energy levels. Manage your s and lows in fuel causing high water per day. (8 glasses) of pints 4 Aim to drink

7 hours

“

‘Where can you go from here?’

“

In order to develop knowledge of how individual measurements are affected by certain health behaviours, consult the operator’s manual and pop-up help screens available in Health Options®.

“

Tools to Help

salt

7 David H. Freedman, 2013, ‘Time-Warping Temptations’ in Scientiﬁc American Mind, March-April 2013, p.49

Final Words

In 5 minutes, you’re unlikely to be able to persuade a person to turn their life around. Aiming to convince the client of wholesale lifestyle change is therefore unrealistic and may be an unhelpful end goal for the practitioner to have. To move the client on from their current position, even if only slightly, is likely to be a more manageable and productive perspective to approach the conversation with. Be aware that if the practitioner appears too preoccupied with a speciﬁc goal on behalf of the client (ie, having them commit to quitting smoking), the client may offer up false change talk and simply tell the practitioner what they want to hear. Similarly, the practitioner should avoid being overly ‘directional’ in their language by remaining neutral and not implying that a certain lifestyle choice is the correct one. Therefore, try to defer from using words that suggest ‘you’re making the right decision’.

The lifestyle choices will carry far more potency if the client can arrive at them without being told what to think. Facts on the consequences of health behaviours should therefore be offered in a professional and clinical manner during the information exchange, with the value-judgements on those behaviours left up to the client to decide on.

If you behave like you’ve got a lot of time, a productive session will occur quicker.

Ultimately, the on-going support that can be offered by an appropriate care pathway is what should continue to inspire the client into altering their lifestyle. Channelling them into this pathway in the ﬁrst place by motivating them to consider the advantages to changing their health behaviour is the central role of the NHS Health Check practitioner.

‘This motivation to change is really encouraging and something that’ll be important to maintain’.

If a client is extremely enthusiastic about making lifestyle change, it would obviously be counterproductive for the practitioner to hamper this enthusiasm by limiting the advice they offer. However, also be aware that over enthusiasm at the point of consultation may subsequently dissipate and therefore it may be helpful to reinforce that

As a general piece of counselling advice, if you behave like you’ve got a lot of time, a productive session will occur quicker. Acting like you’re very short on time will likely cause you to take a lot longer and perhaps achieve very little in the way of genuinely causing the client to consider lifestyle change.

Referances Allison. Jeff, 2013, Intermediate-Advanced MI workshop, What is MI?, 18.02.2013, Cardiff Barth. Tom, 2013, Intermediate-Advanced MI workshop, Motivational Interviewing, 18.02.2013, Cardiff Freedman. David H, 2013, ‘Time-Warping Temptations’ in Scientiﬁc American Mind, March-April 2013, p.49

Final Words

If you behave like you’ve got a lot of time, a productive session will occur quicker.

‘This motivation to change is really encouraging and something that’ll be important to maintain’.

The Script

The fo ll is avail owing script able as a video in the user of the section Healt Diagno stics w h ebsite .

Mark and the Practitioner have been through a health check using the Health Options® software, throughout which the practitioner has been demonstrating engagement through expressing a genuine interest in the client, maintaining eye contact and keeping their body gestures open. At this stage, the practitioner is going to show Mark what his measurements say about his cardiovascular risk.

Mark For the record, Mark’s playing a 55 year old male with slightly elevated cholesterol and blood pressure readings. His weight and drinking are under control and he’s smoking around 20 cigarettes a day. It is important to bear in mind that the conversational techniques shown in this motivational 19

interview can be used and applied regardless of the health issue under discussion. What is said and the information you offer will obviously differ if you’re discussing smoking as opposed to a healthy diet, for example. However, how you say it, the kind of questions you ask and the general approach will remain similar. Some of the important techniques to look out for can be summarised by the acronym O.A.R.S. These are open questions, afﬁrmations, reﬂections and summaries. Bear this in mind when you’re watching or reading the session. There’ll be a couple of brief Timeouts (T/O) to explain in more detail what’s going on.

The practitioner starts with an open question to determine what health factor is most important for him: Ok Mark, so based on the information and measurements, the software is telling us that your cardiovascular risk – so that’s your risk of having a heart attack or stroke at some point over the next ten years – is at 19%. Right ok, does that mean I’ve got almost a 1 in 5 chance? Yes, that’s correct.

And its saying that I’m on the verge of being high risk? The software classes high risk as being >20%, so yes based on these results you’re at the top end of the medium risk bracket. Gosh, right... So given what you’ve learnt about your health status, which of these individual lifestyle factors would you say is most important to you and your health?

For the full video of the following script, go to www.healthdiagnostics.co.uk.

The Script

The fo ll is avail owing script able as a video in the user of the section Healt Diagno stics w h ebsite .

For the full video of the following script, go to www.healthdiagnostics.co.uk.

The Script

It does yeah, but I think I need it at the moment, my jobs quite stressful you see.

Well I suppose my smoking.

And you told me earlier on during the physical activity questionnaire that you’re a freight driver and work a lot of nights. A demanding job... Ok, perhaps you could tell me a bit about how you feel about the amount you’re currently smoking? You said before that you have around 20 cigarettes a day?

Ok, do you mind if we discuss your smoking?

Well it’s quite a bit. It could be worse but the amount I smoke has been creeping up recently. My wife’s noticed too.

Yes, we can discuss it. So family members have been showing some concern?

Great, well why don’t you tell me a bit about your smoking habits? Well I’ve smoked for years, since I was in my teens. I’ve given up for periods before but it definitely helps me cope with the stresses of my job. Ok, so smoking’s been a part of your life for a long time, there’ve been times in the past when you’ve gone smoke-free, but it sounds like smoking is functioning as a bit of a support mechanism at the moment?

T/O: What the practitioner has done predominantly so far is to ask Mark to identify which lifestyle factor is most important to him. Mark’s identified smoking. During a brief intervention or when offering brief opportunistic advice, it’s likely to be easier if you have a single focus. The practitioner has reflected back what he’s said to show that they’re listening attentively. An example of this is when the practitioner reflected that Mark’s

perhaps using smoking as a bit of a support mechanism, that it’s been part of his life for a long time and that there have been times when he’s been smoke-free. When Mark’s expressed some ambivalence and stated that he thinks he needs it, the practitioner has rolled with the resistance, hopefully defused it and re-focussed the conversation towards what he thinks about the amount he currently smokes. Mark’s subsequently revealed some of his family’s opinions.

The Script

It does yeah, but I think I need it at the moment, my jobs quite stressful you see.

Well I suppose my smoking.

Ok, do you mind if we discuss your smoking?

Well it’s quite a bit. It could be worse but the amount I smoke has been creeping up recently. My wife’s noticed too.

Yes, we can discuss it. So family members have been showing some concern?

The Script

Ok, so let me see if I’ve understood correctly, you’ve smoked on and off since a teenager, you’ve had periods where you’ve been smokefree but at the moment it’s operating as a bit of a prop, however you’re family have expressed some concern and would be supportive of any quit attempt that you decided to make?

Perhaps you can tell me some more about your family’s concerns? Well I imagine they’d rather I didn’t smoke if they had the choice, but I don’t think they mind that much.

Yes, that’s all correct Ok, and if I were to ask where on a scale of 1-10 you are in terms of your readiness to change, what do you think you’d say?

Ok, and how do you think they might react if they saw you making a quit attempt or cutting down?

Well I’m probably around an 8 in terms of my wanting to cut down. Mmm... I think they’d probably support it.

Right, so you’d have a strong support network around you? Yes, I think they’d help in whatever way they could.

T/O: After a few reﬂections exploring the family issue – a potential motivating factor – the practitioner is now going to provide a short summary of what’s been

said and afﬁrm the positives. When looking to elicit and strengthen change talk, place the emphasis on the positives.

Right, you sound really confident that you can commit to changing the behaviour. I can actually use the software to show you where your risk would be on this graph if you were to make changes to how much you’re smoking. Oh right, can you? That would be interesting to see. (Show software). Despite Mark being 55 years old, his current heart age is said to be 66. The practitioner changes the ‘what if’ scenario’ to ex smoker, takes the systolic pressure from 145 to 140, diastolic goes down from 90 to 85mmHg. Total cholesterol comes down from 5.30 to 5.00mmol, and HDL goes from 0.8 to 1.1mmol. Mark’s cardiovascular risk subsequently falls by 10%.

The Script

Perhaps you can tell me some more about your family’s concerns? Well I imagine they’d rather I didn’t smoke if they had the choice, but I don’t think they mind that much.

Yes, that’s all correct Ok, and if I were to ask where on a scale of 1-10 you are in terms of your readiness to change, what do you think you’d say?

Ok, and how do you think they might react if they saw you making a quit attempt or cutting down?

Well I’m probably around an 8 in terms of my wanting to cut down. Mmm... I think they’d probably support it.

Right, so you’d have a strong support network around you? Yes, I think they’d help in whatever way they could.

T/O: After a few reﬂections exploring the family issue – a potential motivating factor – the practitioner is now going to provide a short summary of what’s been

said and afﬁrm the positives. When looking to elicit and strengthen change talk, place the emphasis on the positives.

The Script

Wow, so I’m significantly less likely to have a heart attack or stroke. That’s correct, 10% less likely to experience a cardiovascular event. Some relatively small lifestyle changes could take your chances from being almost a 1 in 5 to less than a 1 in 10. It would also slow down the ageing of your heart which is currently said to be 66 years old.

Well Mark, you spoke about the stresses of work before. Research does suggest however that although smoking may act as a stress alleviator in the short term, like alcohol it can actually increase anxiety in the long term. Hence why the effects don’t last and you may feel the same if not worse the following day. If you decided to cut out the cigarettes, you’d also almost certainly see improvements in your energy levels and ability to taste and smell. (Mark’s nodding) There are quite a lot of nicotine supplements available now too which can be helpful in cutting down and quitting. Have you ever tried anything like that before? Yes, the supplements can be really good. They worked for me last time I quit actually. Ok, so when you’ve been successful at making a quit attempt in the past, it’s involved nicotine replacement. Yes, that really worked well actually. I was using patches and going to a group.

Gosh, I see. Can it show me where I’d be if I don’t change? It can actually. I’ll show you, Mark. 65 would take you up to 30% risk – a 1 in 3 chance. Wow, I’m really going to have to do something.

T/O: By this stage the practitioner has received a few green ﬂags demonstrating that the client is likely to be receptive to some lifestyle advice. Remember; 25

keep the information exchange patient focussed, relevant to the individual and check for their understanding.

Oh right, well we provide patches and other nicotine replacement here and yes, there’s evidence to suggest that people are 4 times more likely to successfully quit if they get the help of a support group. Really? 4 times? Are there any locally? There are. I’ll give you that information on the back page of your personal health report.

The Script

T/O: By this stage the practitioner has received a few green ﬂags demonstrating that the client is likely to be receptive to some lifestyle advice. Remember; 25

keep the information exchange patient focussed, relevant to the individual and check for their understanding.

The Script

(hand report) And be sure to stay in touch. I’d love to hear how you get on with it all. Great, yeah, this has been really interesting.

No problem at all. So let’s recap. You’ve got quite a bit more awareness about the state of your heart health and the effects smoking is having on you as an individual, as well as how things could be different. You’ve said that you’re ready to cut down and have thought quite seriously about what quitting might mean for you and your long term health. You know that nicotine replacement is available for you and I’m going to give you some information on local support groups should you decide that you want to utilise those resources (and not forgetting the strong family support network you’ve got around you.)

Yes, it’s been really interesting.

It has. Right Mark, Lets print your personal health report. The back page has signposting information to the local services where you can get any help in taking the next steps towards lifestyle change. And so you’re aware, you can pick up a free quit kit from your local pharmacy. They’re full of helpful tools and advice.

Oh great, I’ll look into getting one of those. 27

T/O: After receiving the green flag from Mark, the practitioner has looked to intensify the change talk, offered Mark some brief advice and begun talking about what the next steps might be. You can recognise green flags when people express desires such as ‘I want’, ability: ‘I can’, need: ‘I should’, commitment: ‘I will’, reasons: ‘I want to do this because it’ll help my weight’, and sometimes non-verbal signs such as nodding. It might not always be feasible and appropriate to get onto this stage with the client if they’re not interested in changing their behaviour. If this is the case the practitioner may find it useful to reinforce ‘ok, that’s your decision. If and when you feel it’s the right time for you, come back and we can discuss it again.’

The Script

(hand report) And be sure to stay in touch. I’d love to hear how you get on with it all. Great, yeah, this has been really interesting.

Yes, it’s been really interesting.

Oh great, I’ll look into getting one of those. 27

Resources

NHS Resources

Workbook And Top Tip Cards

If you want to learn more about how to make every contact count, the NHS have made some really useful interactive e learning tools available. You can get free access to these on the NHS professional learning environment at www.education. nhslocal.nhs.uk

Go to www.healthdiagnostics. co.uk/NHSHealthChecks/ NHSLinks.aspx for links to a number of online resources which deal with all aspects of the NHS Health Check programme. From dementia awareness training, to the latest Diabetes UK reports, the NHS Health Check

Health Diagnostics Resources Health Diagnostics have developed a range of short video tutorials including Guidance on Motivational Interviewing, Blood Pressure Testing, Accurate Finger Stick Technique, Using the Cholesterol Analyser and How to Conduct EQA. View our latest tutorials today by visiting www.healthdiagnostics.co.uk and follow the steps below. • Access the Health Diagnostics website www.healthdiagnostics.co.uk • On the home page click ‘create account’ and complete the form

• After completion of the form, click the ‘client account home’ tab and select ‘training materials’

practitioner will ﬁnd all they need to stay informed. For regular updates on health-related news, follow us on twitter at www.twitter. com/healthdiagsltd

Resources

NHS Resources

Workbook And Top Tip Cards

• After completion of the form, click the ‘client account home’ tab and select ‘training materials’

practitioner will ﬁnd all they need to stay informed. For regular updates on health-related news, follow us on twitter at www.twitter. com/healthdiagsltd

Having Motivational Lifestyle Conversations

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Health Diagnostics Ltd Chatham House Dee Hills Park Chester CH3 5AR Phone: 01244 311811 Email: info@healthdiagnostics.co.uk Twitter: www.twitter.com/healthdiagsltd www.healthdiagnostics.co.uk