Presented by Angela Kinsella-Ritter

Presented by Angela Kinsella-Ritter
HCA Core Training Part 1: A Practical Guide to Health Behaviour Change using the HCA approach Presented by Angela Kinsella-Ritter Welcome the group. Acknowledge the traditional owners of the land if appropriate. Would you like to hear about HCA? Company intro if appropriate. What are your expectations regarding what this workshop is about? Workshop Generic behaviour change pathway P: To introduce the notion of a generic behaviour change pathway and hence the rationale for having a behaviour change pathway to integrate into clinical practice to facilitate change. T: What are the processes that need to occur for a person to take action to get better health outcomes or quality of life? Generate discussion after workshopping the generic behaviour change pathway Does everyone need help navigating this pathway? (No, many people will do this on their own) What is the benefit of knowing that this generic behaviour change pathway relates to all people who try to take action to affect their health outcomes? What is your role/the role of a health practitioner in supporting behaviour change? Ask who thinks that their role is to provide self-management support (discuss self-management if necessary) Help participants to understand that even telling patients to attend referral appointments will be more successful if they use the HCA approach. Key for notes pages: P: Purpose of the slide/content T: Transition phrase/question Key for on-slide prompts: (G##) = corresponding page/s in the HCA Guide for further information PP-a… and ET-a… = prompts for facilitators to ask participants to rate their use of PP and ET in their self-appraisal form. Note: See the CT 1 Extended Facilitators’ Notes for the details of all points to make for workshop essentials.

Workshop essentials Housekeeping & OH&S Timings
Workshop manuals (HCA Guide) Terminology & Glossary (Guide pages xii, xv and xvi) Practical exercises and confidentiality Interaction, questions, comments PowerPoint Attendance certificate requirements Introductions P: To set up accurate expectations and key knowledge for the next 2 days. T: Before we get into the content, we will go through a few housekeeping issues You do need to address each point This slide is about setting the participants up with the right expectations for the workshop (WS), and to ensure there are no grievances with it’s running. Orient the participants fully to the HCA Guide. Include a walk through the sections, turn to the glossary and additional readings and discuss the ‘why, what, how and write your own words’ sections. Encourage participants to write in the notes pages and annotate the workbook on the way through the workshop. Include discussion re why we get participants to work on their own issues (ask participants why we do this). Don’t forget to do facilitator and participant introductions on this slide. Note: See the Extended Facilitators’ Notes for the details of all points to make for workshop essentials.

Patient case demonstration
Video - Geoff Back injury (medical discharge from Navy) Chronic pain PTSD, depression & other psychosocial Diabetes type 2 Prostate cancer previously High cholesterol Weight management issues Resistance from previous experiences Video: Geoff 6 minutes P: to introduce the RICk principle and the style of the HCA approach T: We are now going to watch a video to give you a feel of what the HCA model looks like in clinical practice and to start some discussion. Video Lead in: Geoff has multiple complex issues (-Who has clients with only one issue?!); Geoff comes in with resistance due to the way he was dealt with by a health practitioner; Note of the way the clinician deals with the resistance. We’ll discuss afterwards. Video debrief: What would you like to say about the video? Generate discussion. What were the 3 key variables? Write Readiness, Importance, Confidence and knowledge vertically in the centre of the flip chart. What would be the benefit of asking RICk? What was Geoff’s importance level? Are all our clients going to think it is important? Being able to deal with resistance and low importance is part of what we will be discussing today. What was Geoff’s confidence level? What made his confidence increase? What do you think k stands for? Why is it a little k? When introducing the idea of ‘RICk’, mention that this is an important part of the model presented today, and that we will be examining it closer detail later in the day. Note: See Extended Facilitator’s WS Notes for Geoff video details Geoff 6 minute video

HCA generic behaviour change pathway
Knowledge & understanding Motivation & expectations Decision & commitment Macro View Micro View Decision Line Planning P: To recap on the generic behaviour change pathway (especially if a number of people came in late and missed the introduction) This slide is animated T: This is the behaviour change pathway that we wrote on the whiteboard a little while ago. It shows what needs to occur for people to take and sustain action. Invite participants to turn to the diagram in their manuals, inside the front cover. We will be referring to this diagram a lot during the workshop. The whole of the workshop relates back to the processes in this diagram. Ask participants how much emphasis they usually place on each of the processes in their usual work role. Brief exercise: Considering a health change, where have you (or one of your clients) gotten stuck? 2 min each. In debriefing: ensure that you ask who was stuck above the decision line and who was stuck below the line. Action Self-regulation Build Motivation Build Confidence (G Inside Front Cover)

(WHO 2003; GP clinic audit; Dishman 1988; Oldridge 1991)
The purpose of the HCA approach is to increase adherence for effective health self-management 14-21% Patients who don’t fill their prescription 50% Patients who act on GP referrals to other practitioners and services Overall adherence to chronic conditions treatment including lifestyle changes 25% Maintenance of new exercise behaviours after rehabilitation in the general population, and following cardiac rehabilitation P: To highlight that adherence is a widespread problem that needs to be addressed T: Non adherence goes across adherence to lifestyle and treatment recommendations the all professions, cultures, gender. It’s a human factor. Non-adherence to recommendations is a huge problem across all health issues and in all areas globally. We know that people can get better outcomes if they follow treatment advice. But given these stats people are not following our recommendations a lot of the time. What would you estimate the adherence rates of your own clients to be? (Acknowledge that they are not alone). GP’s who have attended workshops have estimated as little as 5-20%. Clinicians can use the HCA model when clients are not automatically doing what they should be doing – that would be at least 50% of our clients. We will aim to relate to these specific issues and use these as examples to make this workshop relevant to your work. (WHO 2003; GP clinic audit; Dishman 1988; Oldridge 1991)

biomedical focus psychosocial focus
Different roles for clinicians Traditional medical and allied health clinical consultations Client-centred medical and allied health clinical consultations Client-centred clinical programs and services Wellness counselling and coaching interventions General counselling and coaching interventions Focus on individualised assessment, treatment advice and/or education for specific conditions (conducted by clinicians) Focus on individualised assessment, treatment advice and/or education for specific conditions + health behaviour change support Focus on general recommendations and education for disease management, rehabilitation and/or lifestyle change for better health outcomes + health behaviour change support Focus on general recommendations and education for general health and wellbeing + health behaviour change support (not necessarily conducted by clinicians) Focus on improving general wellbeing and mental health + behaviour change support (not necessarily specific to health or conducted by clinicians) P: to show some different roles and indicate where the HCA approach can be used. Also to show the relationship to ‘health coaching’ T: Where does the HCA approach style fit within the spectrum of health care? The following diagram shows where health coaching-based clinical consultations and programs sit in the health change spectrum. The HCA Model of Health Change (see second arrow in diagram below) can be used in any of the categories of practice in the four right hand columns (i.e. all categories except the first column, traditional consultations). So this HCA approach is not about being a health coach per se but rather about using client- or patient-centred approach to support behaviour change in whatever context. “Health coaching” is the two blue boxes, however the HCA approach is broader than that and can encompass all of these areas (except traditional practice without self-management support) In this diagram, each column represents a different role, and all are legitimate in their own right. On the left, traditional medical consultations, focus is biomedical, not a lot of behaviour change support. Client-centred care in 1:1 clinical consultations - Individualised treatment & education, with health behaviour change assistance woven in. Client-centred programs & services by health practitioners. -general edu for disease prevention or management with health behaviour change assistance. This is where many telephone-delivered health coaching programs sit. Wellness coaching -general health and wellbeing, more ‘well’ population, higher focus on psychosocial factors, may not be health clinicians. General counselling –different goals, i.e., reducing psychological distress, housing, social connectedness. Same process though. Note: acknowledge social worker, counsellor or psychologist- already have good behaviour change skills; opportunity to offer peer support. biomedical focus psychosocial focus HCA approach health coaching (Gxi)

HCA Model of Health Change ™
Health change contexts Chronic Condition Management ~ Disability ~ Rehabilitation ~ Disease Prevention ~ Health/Wellness HCA Model of Health Change ™ Health behaviour change principles and processes applicable across the spectrum of health goals and clinical contexts 9 Practice Principles 3Cs: client centred, client choice, client control Call it as you see it Four aspects of goal setting One thing at a time, one step at a time, adding up over time The RICk principle First ask, then offer WAIT til 8 Invite the client to write Trial & error Client first technique Menu of options technique Using your RICk radar Asking RICk Decisional balance technique Turning ANNTs into PETs Tracking & monitoring strategies 10 Step Decision Framework Set the scene & explain your role Identify clinical issues & broad lifestyle & treatment categories Prioritise & choose a category Ask RICk  Make a decision Generate personal goal options Choose & refine an option Create an action plan Identify & address barriers Ask RICk Consider review & referral 7 Essential Techniques P: To establish legitimacy. The HCA approach is based on sound evidence-based principles and techniques. It is a sophisticated approach and it respects clinicians existing skill sets. T: This is the formal model that underpins the HCA Approach The three boxes in the model show the three major components of the HCA Model of Health Change. These are underpinned by 6 knowledge and skill sets that clinicians need to be able to provide self-management support. Prompt participants to turn to page 4 in Section 1 of the Guide to review the knowledge and skill sets. A set of practice principles that are simple tips to help clinicians to apply person-centred communication skills in their consultations. A set of essential techniques to operationalise the practice principles and to identify and address barriers to action. A decision framework or behaviour change facilitation pathway that helps clinicians to decide why a client might be stuck in their behaviour change process, and to do to help to move them on. The framework has 10 steps, but don’t let that intimidate you. You will be doing most of these steps intuitively if you have been a clinician for a while. The framework helps clinician to identify processes that they might try to use more often to be more consistent in supporting patients or clients. In the 3rd box you can see that a decision line has been built into the 10 step decision framework. This decision line matches the one in the generic behaviour change pathway that we discussed at the start of the workshop (see inside cover of the Guide) (G inside Section 1 tab)

What topics will we cover?
1. Overview of the HCA approach 2. Practice principles 3. Essential techniques 4. Setting the scene 5. Above the line processes 6. Below the line processes P: Reinforcing HCA language and informing participants of what the workshop will include before asking what they would like to get out of it. This slide substitutes for introducing the learning outcomes for the workshop. T: The workshop will cover the following topics over the next two days. This morning we will start by introducing the model and nine practice principles that underpin the HCA approach. Then we will discuss how to use a set of seven essential techniques that can be used to identify and address barriers to change. After that we will talk about how to set up face-to-face and telephone consultations to be client-centred, including discussion of documentation and reporting issues. Finally, we will bring the practice principles and techniques together in an intuitive decision framework that helps clinicians to know what techniques to use when in a consultation or conversation. You will note that the flow of the 2 days reflects the flow of The Guide – which we encourage you to write in, underline, highlight, attach sticky notes etc. to help your learning of the material and where to find key content in the book for later reference. We will also discuss implementation and how you might plan to adapt and use the HCA approach with your own clients or staff.

Common patient predictors of non-adherence & poor self-management
“Yes, Yes, tell me what to do” “Don’t tell me what to do!” P: Recognition of relevance for clinicians T: I am sure that you would recognise these types of patients …. …a very general rule of thumb, a common predictor of non-adherence and poor SM is: When it feels like a struggle – when you and the patient ‘butt heads’ or the patient becomes overly resistant. Here the patient is taking an active role, however they are acting defensively due to perceived threat (loss of control, loss of a lifestyle they enjoy, etc.); and When it feels ‘too easy’ – a ‘yes, yes’ patient who seems to go along with everything you say, but is taking a passive role and subtly putting the responsibility back on you By nature, self-management (SM) implies active participation in health. Not all of our patients want to SM their health and change their behaviours and routines – that means hard work!

Behaviours Emotions Situations Thinking
What stops people from taking action to achieve better health and quality of life? Behaviours Emotions Situations Thinking Actions, everyday habits, planning or lack of planning Emotional reactions to things that happen to us, mood states Medical, cognitive abilities, social, physical, access, $, changes in circumstance, clinicians Beliefs, attitudes, expectations & habitual thinking patterns, motivation (RIC), knowledge (k) P: to give clinicians a way to categorise barriers and consider what might be getting in the way for themselves and their clients. This slide is animated T: What do think the clients are going to say are their main barriers? Barriers to Engagement (into program): Suspcision, call contact time/bad timing, not explaining why you’re launching into assessment / questionning; being task-oriented. Action: Laziness Time Weather Children/other people as commitments I lose motivation after a while. Work  other priorities Pain or energy Maintenance: reactions to changing situations. Thinking involves priorities  that’s where priorities sit. Some barriers will impact more on motivation (above the decision line) and some on confidence (below the decision line). All these categories are interrelated, and so one area can affect another and lead to a negative (or positive) spiral effect. Discuss BEST with reference to the typical client profile that the participants just filled out. Identify the barriers that get in the way for these clients. (This brief activity can be done in small groups or as a whole group). Emphasis the categories of thinking and planning in particular Outro: Now that we’ve been talking about the categories of barriers, I’ll pass over to X to discuss what gets in the way for us. Note: Depression is a Situational barrier. If the client is in a state of depression they may need to work on a different goal that is more realistic and achievable so they don’t feel like more of a failure when they are depressed. i.e., we may need different goals and action plans for different situations. (Gix) White Card

What gets in the way for you?
What are the recommended activity levels for adults? Does your own activity level meet the guidelines? If Yes: How do you manage to achieve this? If No: What stops you from achieving this? P: To get participants to understand that not doing what we know we should is a human phenomenon, and that barriers relate to all humans and them to personally. There will be a range of opinion and barriers and facilitators. To relate the participants’ barriers to BEST and categorise them according to BEST. This slide is animated T: In order to understand why adherence is a problem for our clients or patients, let’s look at what gets in the way for us using exercise as an example. Ask: What are the recommended activity levels for adults? Ask for different ideas i.e., what is ‘most’ days? Comment: It is interesting, that even in a room of well educated health professionals, there is ambiguity with guidelines for exercise. Ask: What about for weight loss? How would a sedentary, overweight patient would react if they were advised to exercise for minutes? Ask: What about ourselves? Raise your hand those of you who have engaged in at least 30 minutes of moderate to high intensity exercise for at least 5 days of the week for a period of two weeks? Or at some point in time. Ask: When you did meet this, how did you manage to do it, what was your strategy? Reflect on answers i.e., canine accountability, social accountability or social enjoyment, thinking i.e., reminding self of benefits, planning, routine, reframing. Ask: On the days you did not exercise, what got in the way for you? Acknowledge: weather, time, children, thinking, travel etc What types of (BEST) barriers are these? Points to make through workshopping: Government guidelines can be confusing and can be overwhelming to our patients Strategies (facilitators) and things that get in the way (barriers) affect your own adherence  relate back to our clients These relate to different types or categories (BEST)  direct clients to white cards

What do clients want? How do you know when a client is ready to take action? How do you know your client is not ready? What do you want your clients to do when they leave your consultation? What do clients want? P: Where’s the client coming from? We can’t assume the client wants what we want (we can have conflicting agendas). This slide is animated T: Let’s look at what happens in a consultation. Clinicians can pick up signs of readiness from body language as well as language. Use RICk radar – seeing and hearing the signs Clinicians have an agenda but this may not be congruent with what the client wants As human beings, we all want the same thing; to feel better, to get on with their life. Optional point: This difference in agendas can also be between the health system and the client. The health system and organisational system largely defines the Health professional’s agenda, in that it impacts the assessment protocols, treatment, documentation, and other requirements of the health professional, and this creates a situation where we have miss-matched or competing agendas. Additional information: What do you observe when your patient is ready to change a particular behaviour? What about on the telephone? This is where as clinicians we can use our RICk radar. If someone mentions that a patient is ready if they turn up. (Patient’s role) Ask the whole group, “Do we automatically assume that they are ready if they just turn up”. What are the signs that your client is not ready to change?” What about on the telephone? As health professionals we have an agenda. We want our patients to exercise, use equipment, take medications, attend a program, or whatever it might be in your context, because that will help them to achieve better outcomes”. But what do our clients want? If the group is not forthcoming, ask, “in general what do human beings want?” Our motivations include: independence, stay out of a nursing home, mobility, feel good, function well, be happy, free from pain, play with the grandkids, a magic pill, others… It’s interesting, our agenda and the client’s may or may not be aligned, our motivations for patient change are usually a long way removed from what patients want.

Usual clinical practice processes:
E-b Treatment Plan or Recommendations Diagnosis Clinical Decision-making Algorithm Clinical Assessment Do you regularly check that your client is ready, willing and able to act on your recommendations? What do you do if they are not? P: We are not usually taught in our university training to assess motivation and self-efficacy as an integral part of our assessment, diagnosis and treatment processes. T: Our agenda is to follow these clinical processes However, how many of us were taught to regularly assess whether the patient is ready, willing and able to do the things that we advise them to do? What do you do if they are not  build motivation, readiness and confidence…. E-b = evidence-based

Complementary clinical pathways: Clinical condition/health behaviour change (HBC)
E-b Treatment Plan or Recommendations Diagnosis Clinical Decision-making Algorithm Clinical Assessment E-b Behaviour Change Recommendations RICk Clarity HBC Decision-making Algorithm HBC Assessment P: To introduce the notion of a complementary behaviour change pathway as a systematic approach to addressing motivation and self-efficacy. T: Highlight that the system already tries to meld these together. Systems trying to do this already, but it’s not perfectly aligned about how you’re going to do this, but it’s moving towards this , hasn’t been updated in a while aiming for Jan 2013. This workshop is about giving you a behaviour change pathway to complement your usual clinical pathways so that you can support behaviour change in your clients. (The HCA approach provides clinicians with a framework and practice principles so they can be more effective at summarising the medical issues and delivering information in a way that makes it more likely that the client will decided to follow treatment recommendations AND take the necessary actions. The HCA approach meshes our agenda as clinicians, with the client’s agenda. RICk = readiness, importance, confidence, knowledge (Gx)

Clinical & self-management aims - examples
Engage in treatment Manage clinical risk factors Attend referral appointments Manage medications Maintain independence Monitor symptoms Manage fatigue Communicate with doctors Manage time Increase mobility Manage acute/chronic injury Have tests and check-ups Prepare for death Do rehabilitation exercises Manage BP, cholesterol, BGLs Manage chronic pain Manage mood/stress Re-engage socially Use public transport Use aids and equipment Improve nutrition Increase activity levels Damage control Reduce alcohol/smoking Return to work Other? P: Show the breadth of treatment and lifestyle categories that can be addressed using the HCA approach T: This pathway will help you to achieve these sorts of clinical & SM aims, and be systematic and consistent in your approach. There’s a common misconception that this approach is just about lifestyle change. You can see the broad range of categories which include specific treatment goals as well as quality of life categories and things like damage control. E.g. adolescents with T1 diabetes - knowing they are going to drink, the goal may be to minimise the risk or harm. Turn to page Gx in your manuals and write in any of the broad lifestyle or treatment categories on the slide that relate to your work. Add them to the list on that page. (Gx)

What are the clinical and self-management aims for your patients or clients? What are the adherence issues? P: Focus participants on how they could use the HCA approach in their own context T: What are the lifestyle goals/self manaegment and categories you’re working on (In your system) Given that adherence is a problem, what behaviours or actions are your clients not doing that you want them to do? Whiteboard Exercise: Write these behaviours on the white board. Divide the white board in half. Write two titles 1) lifestyle 2) treatment/self-management. Suggest any common behaviours that were not mentioned or to get the ball rolling. Notes: What are the different treatment and lifestyle categories relevant to the participants? If participants mention general things such as “take responsibility”, drill down and ask what would it look like or how could you tell that they were physically doing it? These things are not just diet and exercise and other lifestyle categories but could include taking medications, visiting a doctor, dressing a wound, having a shower, attending a program, risk assessment etc.). Refer to list on page Gx for ideas. Make the point that people are not doing these things because of the presence of BEST barriers. Keep this list on the whiteboard and keep drawing examples from it during the workshop to tailor the content to the participants Treatment: wound care, specific nutrition/supplements, specific exercises, symptom management, medication adherence, manual handling, receive services, attend appointments, manage pain, monitor symptoms … Lifestyle: Nutrition, general activity levels, smoking, alcohol, drugs, stress management, oral hygiene … General life categories: find work, attend appointments, time management

Section 1: Overview of the HCA approach
A behaviour change methodology for use by clinicians and health services within their usual clinical consultations and programs T: Section 1 provides an overview of the HCA approach including (briefly) the underlying model, theoretical foundations and evidence base, the main components of the model and some of the implementation challenges associated with this type of approach.

Client behaviour change pathway
The HCA model of health change (HCA approach) Integrates patient-centred communication and behaviour change support into a clinical practice decision framework Client behaviour change pathway 1. Practice Principles 2. Essential Techniques 3. Decision Framework Decision Line Build Motivation Build Confidence Knowledge & understanding Motivation & expectations Decision & commitment Planning Action Self-regulation P: To remind participants of the generic behaviour change process, and give them a brief summary of the practice model they have been shown that helps them to facilitate behaviour change. Note: this is also to give any staff given the task to present what they have learned to other staff a way to accurately and briefly describe the our HCA approach. T: Yesterday we started off talking about how people naturally follow this sequence when they take action to self-manage their health. However, we also know that people will get stuck along this pathway and hence will not take the actions that would get them better health or quality of life outcomes. Along with the Generic Behaviour Change Pathway, which is on the inside cover of your guides (indicate), the HCA approach incorporates four key elements that enable clinicians to facilitate this pathway in a systematic and time effective manner. These are: The Practice Principles, which enable practitioners to embed client-centred communication into every consultation with clients; The BEST barriers concept, which allows practitioners and patients to better identify and address common barriers to change both above and below the decision line; The Essential Techniques, which are utilised either in all situations or in particular circumstances to enable patients to progress towards successful change; And the Key Questions, which represents the clinical decision making to bring all of this together. You have all of these elements in your Guide and on the two white cards (hold up). These can be used to quickly summarise our approach to any other staff who would like to know what you have worked through in our workshop. But, it is not a magic pill!

Key concepts Clinical information and treatment advice is presented in a way that enhances patient knowledge, understanding and engagement A decision framework is provided for clinicians to quickly identify and address adherence issues (barriers to patient engagement) The approach increases patient motivation and self- efficacy for following treatment advice and builds patient self-management skills P: To outline the main concepts of the HCA approach. T: The key concepts include: (read from the slide)

Purpose of using the HCA approach
Systematically embed a patient-centred approach into clinical practice and services Consistently support patient health literacy, decision-making and engagement Increase and support patient adherence to evidence-based lifestyle and treatment advice Provide a common language and clear, consistent expectations for patients and clinicians across disciplines P: To outline the purpose of the HCA approach T: The purpose of embedding the HCA approach within our organisation it to….. (Read from the slide)

Patient case demonstration
Video - Terry CAD, heart attack Hypertension Diabetes T2 Obesity, Lap banding Gall bladder removed Video – Terry Steps 1-4: 5.5 minutes P: To demonstrate the consultation style going through the above the line steps T: This video shows you what a conversation might look like above the decision line. This is a REAL interview with a real patient. All videos are done in one take with no scripting Video content: Clinical Issues: Gastric banding, blocked artery, gall bladder removed, BGL, Diabetes T2, Obesity. Chosen issue to work on: Weight management (to address yo-yo dieting) Motivators: vanity, social engagement, confidence to do things in life, energy & interest, wife’s concern, worthwhile life. I = 7, Past failure meant C = 4 Points to make in the debrief: Note how the clinician searches for personal motivators rather than health education What alerts us to his low confidence? Previous unsuccessful attempts / past failure (yo-yo diets) Continued weight gain despite lap-banding “It” keeps coming back (no control) Terry above the line video

Key questions above and below the decision line
Does the client know and understand the broad lifestyle and treatment categories applicable to their condition/s? Have they been assisted to collaboratively prioritise these? Are they ready, willing, able and committed to taking action? What options do they have for taking action in a particular category? What is their personal goal and plan? Are they confident they can do this and what might get in the way? Will I review the client and what other support do they need? Decision Line Ready to Take Action Macro View Micro View P: To provide another (simpler) way of thinking about the 10 step framework. This slide is animated T: When you are in a consultation, these are the questions that you can consider to help to support behaviour change for your clients or patients Note: Orient participants to the diagram on the inside back cover of the Guide Answering the questions helps you to identify where your client or patient might be in their behaviour change process (above the decision line or below the decision line). Remember that the decision line is the point in a conversation that a person decides that it is in their own interests to take action to follow treatment, lifestyle or some other recommendations. This line represents a commitment to do something. Above the decision line the main barriers that stop people from taking action are motivational Below the decision line the main barriers that stop people from taking action are things that impact more on their confidence Relate this diagram back to Terry in the video: where is he stuck in the generic behaviour change pathway? Ask participants a series of questions to help them to reflect on whether or not they use each of the processes represented in the diagram in their own practice. E.g. ‘Think about your typical clients. To what extent do you currently …..’ Does this fit in with your normal clinical process? Build Motivation Build Confidence (G5)

How can I assist this patient, to achieve these specific health outcomes, at this point in time, given their…..? Current clinical issues Current psychosocial issues Current level of readiness Current barriers to taking action Current knowledge levels Current life circumstances Levels of ability, and Consultation time constraints P: To help the participants to consider that the HCA approach might be useful to them personally. T: When a client comes into your consultation, the challenge is to answer this quite complex question: How can I assist this person to achieve these outcomes, with all of these givens? Even if you are working with many people the same clinical issues it is the individual factors that makes every case different and therefore need a slightly different approach. This is why there is no ‘one size fits all’ solution, and why clients need tailor-made support and strategies. The HCA approach helps you to answer this complex question.

What’s the evidence? Evidence-based health behaviour change principles and techniques Health behaviour change theory Brief motivational interviewing Solution-focused counselling & coaching literature Cognitive behavioural counselling techniques Health coaching literature Chronic disease prevention and management programs The HCA approach bridges the gap from theory to practice P: To provide legitimacy and reassure participants that the HCA approach is founded on evidence-based practice. T: It was mentioned before that the HCA Model of Health Change is drawn from the evidence-based literature. These are the bodies of literature that it is drawn from. The model bridges the gap from theory to practice. It helps clinicians to apply all their knowledge of health behaviour change in a consistent and practical manner. HCA is happy to work with any organisation that would like support with developing, implementing and evaluating the behaviour change components of their programs.

Applications Primary Care: General practice, allied health consultations and programs Community : Early Intervention in Chronic Disease, Hospital Admission Risk Program, NSW Chronic Disease Management Program – Connecting Care in the Community, Home and Community Care, Cardiac Rehabilitation, Heart Failure, Diabetes Management, Mental health, Aged care, Disability Services, other prevention and disease management support services Population Health: NSW/ACT/TAS Get Healthy program, NSW Live Life Well Diabetes Prevention program, VIC WorkSafe WorkHealth Coach program Research: Deakin University NHMRC (HIPP Study/healthy pregnancy); Melbourne University (knee osteoarthritis nurse coaching to support physiotherapy interventions) Ottawa Regional Cancer Foundation (Canada): Patient support coaching for cancer survivors Corporate health services P: To provide legitimacy and show the breadth of application of the HCA approach. T: As you can see the HCA model has been applied in many different settings. Notes on applications: HCA came into being as a training organisation by working with Victorian chronic disease management and prevention programs (EICD and HARP). The Get Healthy program provides up to 10 free telephone based health coaching sessions for anyone in in NSW/ACT and Tasmania with mild to moderate risk factors for chronic disease (diet, exercise, weight management). The program been running in NSW since 2009 and has been formally evaluated by Sydney University and papers are awaiting publication. The results have been positive. NSW: Diabetes prevention program, ‘Live Life Well’. HCA is currently providing training across NSW to Local Health Districts in relation to the NSW Severe Chronic Disease Program (Connecting Care). Free work health checks are now operating in Victoria for workers who are identified at moderate risk of diabetes (AUSRISK assessment tool) or at risk of cardiac disease. They have access to a free telephone-based WorkSafe Victoria WorkHealth Coach health coaching service (10 calls over 6 months). HCA is working in collaboration with Deakin University on an NHMRC-funded healthy Pregnancy research program (HIPP study). Janette Gale (HCA MD) is an Associate Investigator on this grant. HCA is working in collaboration with Melbourne University on a study that looks at nurse-delivered health coaching to support a physiotherapy intervention for knee osteoarthritis. HCA has also worked with many GP networks and divisions and has trained private allied health practitioners, practice nurses and GPs. HCA works with Ottawa Regional Cancer Foundation in embedding behaviour change in their programs. HCA offers consultancy to corporate health services. As at October 2012, HCA had trained over 5,000 clinicians and other practitioners in their Core Training Part 1, 2-day workshops and has worked with many organisations to help them to embed the approach into their practice and programs.

Behaviour change support challenges for clinicians
Knowledge & skills Clinician RICk Management & Systems support Clinician role (perceived & actual) Client’s role perceptions Time? Attitudes of colleagues Client’s characteristics Behaviour change support challenges for clinicians P: To acknowledge clinician and organisational challenges associated with practice change to embed the HCA approach. This slide is animated T: While being patient-centred and facilitating self-management will improve outcomes, it is not a magic pill, what do you foresee are the difficulties when using the model in your role? This is an opportunity to workshop and discuss the participants’ barriers before moving on. Allow participants to voice their own doubts and encourage the group to try to offer solutions to the barriers raised (e.g. yes, that can be a barrier, how could you overcome this?) Highlight any additional challenges that were not raised by participants Common challenges raised: Time: a challenge! See the next slide. What if you don’t end up working on the referral issue? See sample letter to referring clinician, Appendix G, page 89 HCA Guide. HCA has asked GPs if they would like/appreciate receive a letter such as this. GPs have said yes as they are then kept in the loop. Client Perceptions: How many clients think that their role is to turn up? How do you get around that? Need to explain your role as a health practitioner. How do you explain your role when using HC? I don’t know what is going to suit you in your own life, I can tell you what you need to do, but I can’t tell you how to do that on a daily basis because I don’t know your personal needs and preferences. If relevant, mention the tendency to hide behind check lists (that’s what they are used to). Suggest: If they fit this category they might like to try putting their pen down whenever in the clinician role during this workshop. At every level within organisations, there are challenges. It is not just our clients who need to be ready, willing and able. Staff working with clients need to be ready, willing and able to change the nature of their practice. – We have no expectations that you’re across the line. But if the system does not align with what they have learned from a workshop, then this is going to pose a challenge. Not only does the system need to align with what staff are doing, there needs to be support from management in order for change to occur. Often we see significant management support and clinician support in theory, but if the system is not perceived to support clinicians, they will not take action. Possible Workshopping Points: All of you will be great clinicians using your skills to get better patients outcomes, but we all work in a health system. What are some of the frustrations about working in health? Paperwork (not going to add, gives you a different way of communicating with HP, common language) Other HP undermine your efforts (helps you clearly explain why you are doing what you are doing) Systems/programs don’t account for the individual (helps you tailor advice and explain why doing that to other HP) No support to develop skills (we work with managers so they can give you the support you need) (Sample Letter Appendix G, p. 89)

Consultation time Less Time More Time Targeted assessment
Targeted education Low complexity High RICk Fewer barriers Global assessment Global education High complexity Low RICk More barriers P: Time is consistently mentioned by clinicians as the biggest barrier to providing self-management support. This arises from the perception that providing behaviour change support is an ‘added extra’ to our usual practice, rather than a different way of conducting our practice. T: Less time…… Only Assessment but don’t muddy it with education/ feedback, summary + clinical recommendations tailored to the client (based on healthy guidelines). Ask the client their opinion of what you’ve just told them (what are your thoughts about that). What are you already doing? {Might need to help them with something else, because they } What would you benefit the most from working on with me today. We know that none of you have a lot of spare time in a consultation. This slide helps us to look at what we can potentially change in a consultation and what we can’t. How can you spend your time most effectively? The HCA approach is about changing the way we use our time in consults, not about adding something extra to our usual tasks. Using this approach is not a case of doing 1) assessment, 2) treatment protocols, 3) education, 4) self-management support if we have time for it. In fact, it is about weaving in behaviour change support throughout each consultation. To make the most of your time, depending on your role, sometimes assessment and education can be applied in a targeted manner rather than assessing and educating every client in the same way. This can save time to focus on specific barriers to change if they are present. A growing number of GPs are using this approach in very short consultation times. They mainly focus on the above the line steps. The optional techniques are only used when necessary to address certain types of motivational and self-efficacy barriers. Video – Young Geoff insulin pump Open/Closed questions: Young Geoff 2.75 mins P: To encourage discussion about open vs. closed questions and about what can happen when clinicians are under time pressure and revert to a process-oriented practice style. T: Let’s have a look at what can happen when a clinician is under time pressure. [play clip part 1 then pause the video] What did you observe/what would you like to say about that? What were the potential problems with the communication style? Who’s benefit was the consultation for? What effect might that have on clients? Do you think this approach will lead to adherence to recommendations? [play clip part 2] Comments? Help the participants to note how in the second clip the clinician was actively looking for possible barriers, given that social barriers to using an insulin pump or checking blood glucose levels might be anticipated in this age group. Outro: We’ve finished giving you an overview of what the WS is about, so now we’ll hand over to X to introduce the practice principles. Insulin pump video

Who should we spend behaviour change time on?
Clients who are clearly not interested in your advice? Clients who are undecided (ambivalent) or couldn’t be bothered? Clients who are motivated but lack confidence? Clients who are clearly motivated and confident?    P: To help participants to understand that the HCA approach is not a ‘one size fits all’ approach and to know where to use their time to greatest effect. Animated slide T: Would you use all of the techniques that we have run through with all clients? Workshop these questions with only the slide heading showing When would you use each technique? Which of the Essential Techniques are optional, and which would you use all the time? [i.e. the essential techniques are essential to know if you are going to facilitate behaviour change, but some will not be used unless there are specific barriers to address] In terms of RICk profiles, which clients would you use the optional behaviour change techniques with?  34

RICk = Readiness, Importance, Confidence, knowledge
Section 2: HCA practice principles P: To introduce the HCA Practice principles as the foundation for client-centred communication - to build strong rapport and achieve better client engagement. This slide can be used to workshop the practice principles or simply to introduce them. T: This section looks at the HCA practice principles in detail. Please turn to the second tabbed section in your manuals to follow the slides, and look at your white card in front of you. Each practice principle provides a simple way to keep in mind some of the fundamental underpinnings of the client-centred communication approach. This graphic is on the reverse side of the Section 2 divider tab. As we go through, we will be asking you to use your self-appraisal form to consider your current practice style and consider to what extent you’re already using these principles. Re PPETs self appraisal: the good thing about this is that it is your own personal tool to reflect on how you are going with each principle. No one else needs to see your evaluation, we will not be looking at it. RICk = Readiness, Importance, Confidence, knowledge (G inside Section 2 tab)

People have a need for autonomy
The 3Cs of health change People have a need for autonomy P: to introduce and explain the 3Cs principle This slide is animated T: the HCA approach is a client-centred approach that respects client choice and promotes client control This principle reminds us to treat each patient as an individual with their own unique needs and preferences. Patients have a fundamental right to make their own decisions regarding their health, even if that decision is not to follow treatment recommendations. If we can help our patients to make health enhancing decisions, this can increase the likelihood of their achieving better outcomes. When patients feel that they are respected as a person and are being offered choice and control over their situation, they will be more likely to trust and listen to their health practitioners and follow their recommendations. Being client-centred means meeting the client where they are at (in terms of culture, language, cognitive ability etc.) (G19)

Traditional care & client-centred care
How are these different? P: To highlight the differences between the traditional medical model and client-centred care. T: In order to effectively facilitate Self-Management, we need a different model of care from the traditional acute care approach: to work with the patient, rather than doing things for or to them. Workshop: What does it actually mean to be patient/client centred? What are the differences between traditional care and client-centred care? Invite participants to look at the table on page 20 of the Guide. How are these approaches different? Optional Individually reflect on which model they think they work in and/or which processes they currently relate to in their work. Play ‘what is patient empowerment clip’ to promote discussion. Need internet access to do this as it is an NHS video on YouTube. (G20) What is patient empowerment?

Is this patient-centred?
Diet’n GP Diab Ed Patient Counsellor Nurse Ex Phys Pod’st Physio OT Take Meds Use Aids Monitor Symptoms Exercises Nutrition Attend Appoint’s Groups Quit Smoking Pathology Rehab Program Move More Self- manage P: To draw awareness that clinicians need to widen their focus to recognise that patients can easily become overwhelmed by the demands of clinicians and the medical system (even though the system has benevolent intent). T: Speaking of the traditional model, this situation is quite common in the medical system. Patients often see a number of clinicians and services. A typical patient may be seeing multiple health professionals, and even if each clinician sets only one goal, look what that does to the patient. Is that client-centred? This is what we call being ‘goaled to death’. This is what we are trying to avoid. But, unfortunately it is what happens in many well- intentioned programs that require patients to see multiple health professionals. What happens when each health professional wants patients to set multiple goals? The drop off rate for goal achievement is rapid as you add more goals.

Common patient/client responses
Fear Hopelessness Guilt Resistance Frustration Despair P: To highlight how strong emotional responses of any kind can lead to non-adherence. T: When patients feel overwhelmed, confused or out of control, these are some of the emotional responses that you might see. These responses are common for people who are: newly diagnosed, have multiple or complex conditions, are suffering burn out from managing chronic health conditions don’t have the confidence or resources to cope have been poorly handled by the medical system The common theme among all these reactions is that they are likely to lead to the same response… [next slide] Confusion Anger Shame Resentment

Cognitive, behavioural & emotional avoidance response
P: Avoidance or denial is common reaction and there is a reason for it T: …Cognitive, behavioural and emotional avoidance! This reaction is particularly to be expected if fear tactics are used when the client has low confidence in being able to take any effective action to fix the situation. In another words, if I is very high and C is very low, this is what happens – the head in the sand reaction that leads to taking no action. If someone is in ‘denial’ it probably means that either they don’t understand their situation properly, or there is another personal barrier getting in the way of them committing to take action.

Communication What not to do: ‘Tell’ people what to do Argue the point
Use scare tactics with someone low in confidence Using judgemental language Overwhelm people by expecting them to do too much Overwhelm them with too much information P: To highlight that communication can be a facilitator or a barrier and that strategies that are commonly used by practitioners can be ineffective or harmful This slide is animated T: Here are a number of strategies that are almost guaranteed to get the “head in the sand” (avoidance) response from people… What are the potential problems with these strategies? What does motivational interviewing have to say about arguing the point with patients? How does it feel when you are asked why did you do that?, or Why aren’t you doing …? [Asking a direct ‘Why?” question can sound judgemental] What is a better way of asking this? [e.g. What is it about that .……that’s not working for you?, What is it that you find challenging about ….?]

Client-centred communication process
Before conducting assessments, delivering education or asking a lot of questions for any purpose: Explain what you’re about to do Ask for permission Launching into questions without explanation can reduce rapport P: To provide a structure for delivering any technique in a client-centred way T: Poor communication can be a barrier, but client-centred communication used throughout consultations can build mutual respect and trust and help to engage clients in active self-management. The process on the slide can help you to operationalise client-centred communication. Explaining what you’re about to do e.g. an assessment, asking open ended questions or using a particular technique. Ask permission in a casual way [e.g. is that okay with you?] Then deliver the technique content/assessment/etc. By keeping the client informed of what you are doing and asking their consent before continuing, you can lower resistance and increase client engagement while building rapport. Invite participants to complete the relevant question on their PP and ET self-appraisal form PP - a

Avoid playing the practitioner-patient game!
Call it as you see it (or hear it) Avoid playing the practitioner-patient game! P: To introduce and explain the principle This slide is animated T: Read this in your books (5 min) What does that mean? {Read and discuss and how do you think you’ll use this in your context here at Medibank?} So what do you think this principle is about? This principle refers to engaging in open and honest dialogue with patients when it is apparent from their body language and verbal cues that they are not ready, willing and/or able to engage in health change Clinicians need to be able to raise difficult issues for discussion if these are acting as barriers to a client taking action. Avoiding these conversations can result in the ‘practitioner-patient game’. This is where a client pretends to take a clinician’s advice and the clinician pretends that the client will act on their recommendations. The end result of this game can be high use of medical services and clinical time for minimal health benefit, ending in dissatisfaction for both the clinician and client. Acknowledging low motivation by calling it as you see it can give clinician and client an agreed starting place from which to build motivation. Invite participants to complete the relevant question on their PP and ET self-appraisal form Outro: I’m going to hand you back to X to discuss the next practice principles PP - b (G20)

Specific personal health goals Broad lifestyle & treatment categories
Assessment 4 Motivational drivers 1 Clinical targets (physiological) 3 Specific personal health goals 2 Broad lifestyle & treatment categories P: To introduce and explain the principle This slide is animated T: This principle is about effective goal setting. We often set goals within the health context, but it is more complex than it might seem. There are four aspects of goal setting we need to consider in order to set goals for patients effectively. These are the 4 aspects. We tend to want to achieve clinical targets, or physiological measures or indicators for health. For example, for Metabolic Syndrome, they are cholesterol, BP, BGL, & waist circumference. Once we’ve got these targets, we tend to jump this way (indicate right) and give a lot of micro-advice e.g. ‘walk around the block and switch to low fat diary’. These are very specific daily or regular behaviours that we know can affect the clinical indicators. What might be the potential problem with doing this?  Draw out point that patient doesn’t have an overall understanding of how these specific recommendations relate to their health condition, they don’t know how to substitute or modify the recommendations if they don’t work for them, and they don’t know how to progress their health behaviours over time to increase the outcomes they achieve. So the missing piece of the puzzle is that before we give specific recommendations, around this way in the circle and ensure that our patients understand the broad treatment and lifestyle categories that they can take action in over time. This sets the foundation for self-management. So for metabolic syndrome, the broad categories that relate to that would be a combination of Lifestyle: cardiovascular activity levels, strength, nutrition, alcohol, smoking, possibly stress management, as well as treatment categories such as they may need to be on medication, get specific education for instance from a diabetes educator, and monitoring symptoms or the clinical indicators. Once the patient understands those categories, the next step in the process is to collaboratively prioritise them and focus on one at a time so that the you can help them to come up with appropriate specific health goals that are manageable and achievable for the client within each of the categories. This will close the loop over time. This is how we empower patients to effectively self-manage. When people have this knowledge, you see people making spontaneous changes and actively taking responsibility for their own health management. (Without this knowledge, the patient is unable to effectively SM, and given that we often hear practitioners say ‘I just want my patients to take responsibility’, we can see how this is the missing link) Could use this example here: Client who wanted to travel around Australia  Can we link this to health goals? Yes, the exercise I need to do and meds I need to take, so that I remain fit and healthy in order to travel around Australia. The final aspect of goal setting is the ‘what’s in it for me’. If people don’t have their own internal motivation, they’re not going to do any of this. Given that the things we want people to do for their health are generally unappealing and take a lot of time and effort, there needs to be a strong driver, or a reason that is personally important and tied to the person’s values, in order for them to make the change and stick with it over time. This is the element of goal setting that enables the patient to progress all the way through the generic behaviour change pathway to achieve self-regulation of new health behaviours over time so that they can change their clinical targets. You can tie it all together with simple appropriate documentation. We already do number 1, the care plan or treatment plan. Often number 3 is captured in the clinical notes. The big gap is at number 2. This doesn’t need to be complex, you can do this in a simple table and then the client can take it away with them, as well as sharing this with other clinicians and services so that they know what has already been covered, cutting down on overlap and increasing consistency of care. You will have an opportunity to practice using the Patient SM Plan as an exercise later in the WS, and this is a key piece of documentation that allows you to facilitate behaviour change and SM. Read the relevant sections in the Guide (especially the ‘Why is it important?’ section) relating to this principle. Discuss goal hierarchies/menus of options. Invite participants to complete the relevant question on their PP and ET self-appraisal form Menu of options Personal action plan (G21) PP - c

Patient assessment data: clinical indicators & risk factors
Diabetes CAD Asthma Arthritis Injury Obesity Nutrition Meds/ Treatment Attend Appoint’s Exercise Monitor Symptoms Info/Edu P: To help clinicians to understand the need to provide clients with an overview of all the broader areas of action that they need to address over time to get better health/QOL outcomes This slide is animated T: In the health system we need to assess clients to establish diagnoses, clinical indicators and risk factors. Once we have a diagnosis we can then provide information to the client about what to do to manage or improve their health. We have goals related to the clinical (physiological) indicators for each condition. But these outcome goals don’t tell patients what to do to self-manage their health. Rather than straight away giving patients a lot of very specific advice about how to self-manage on a daily basis, we need to help them to understand the broader categories of actions that they need to pursue for overall management of their health. (click) This is represented by the line of green ellipses in the diagram. As health professionals we know that with many conditions there is a finite set general categories of behaviour change or action that the client could work on to improve or manage their condition. For example (click) someone with diabetes needs to take action in these areas. What about for asthma? (click) What about for all the other conditions? (click) Do you think that clients always understand that reducing fat in their diet for their diabetes might also have an impact on their arthritis? It is not uncommon for a patient who has been to a diabetes educator, a dietitian and a cardiac rehab program to think that they have three different diets to follow! (click) So after completing any assessment that’s required to determine the patient’s clinical issues, step 1 in the HCA approach is ensuring the client understands their health conditions, the major categories of action that will help them to self-manage their condition/s and the rationale for taking action in these categories over time. Ensure the patient knows: 1. what their health issues are 2. the broad categories of actions required to manage these health issues

Different clients will have different motivators
What might motivate the following groups of clients? Children? Teens? Working age adults? Seniors? People with disabilities? People with mental health issues? Different cultures? Others? P: To acknowledge and highlight that different groups of clients will have different motivators. We can’t assume that what works for us will work for other age groups, cultural groups or the other gender. This slide addresses comments like: This approach wouldn’t work for my clients because they are all old! OrThis wouldn’t work with children! The point is to treat each person as an individual and find something (if possible) that would motivate them. This slide is animated Workshop: T: Given that personal motivation is a critical aspect of effective goal setting and taking action what are the sorts of things that might motivate the following groups of clients that you work with? Workshop with the group the main motivators and values for the participant’s client groups To give you an example of linking motivation with clinical goal-setting. Example here (if not used at four aspects of goal setting). We had a participant recently that said ‘my clients keep wanting to set goals that are not health-related!’. I asked him for an example, and he said he has one guy who wants to get a caravan and travel around Australia. So what do you think of that? Is it a good goal? Is there any way to connect this to health? Of course there is! So his goal was that he was going to take his medication regularly and take a 30 min walk daily so that he would be fit enough to travel at the end of the year. This is linking the motivator with the clinical personal goal statement. Another example: Example from P who worked with Afghan ladies who don’t perceive exercise as important as they feel it’s a selfish activity; but what they would do is walk to the next suburb to source better food for the family to prepare their meals – so consider linking health goals to the things that the client values which is often not health itself. Outro: I’ll hand you back to X for the remaining principles (G23) Strategy

PP - d (G25) P: to introduce and explain the principle
T: We’ve just been discussing that there are many things our clients with complex health issues need to do, and this can feel like climbing mount Everest. It’s a principle and don’t take it literally. One thing at a time, one step at a time, adding up over time is a principle that can help to prevent clients from becoming overwhelmed at the number of things they have to do and the complexity and difficulty of some of these things. The idea is not to necessarily only do one thing, but to focus on one thing at a time, make sure the client knows what they need to do and is confident that they can before moving on to discuss the next task. However, some clients will only be capable of doing one thing at a time. In a consultation, focus on one issue (lifestyle/treatment category) at a time. If time allows and the client can deal with multiple tasks or actions, you can go on to focus on additional issues. There is also a misconception that the steps have to be ‘baby’ (small) steps. However, in accordance with the client-centred practice principle, the size and number of steps that a client might tackle at once should depend upon their choice and capability. They could be large, depending on the client. The adding up over time part of this principle refers to the notion that we should not be setting personal goals with clients that won’t ultimately help them to achieve better outcomes (goals that are irrelevant). However, it is okay to set goals around things that are acting as barriers to health behaviour change. These may be necessary before setting more direct health-related goals. E.g. talking through how a person might discuss an issue with their spouse so that they can make the changes they need to make to their lifestyle. Some clients try to make large changes but then fall off the ladder. Explaining the 10% rule can encourage them to make sustainable and incremental changes (refer to their manuals) Has anyone here heard about the term just noticeable difference (JND) Invite participants to complete the relevant question on their PP and ET self-appraisal form PP - d (G25)

} The HCA RICk principle Readiness Importance Confidence knowledge
Action P: To introduce the RICk principle in more depth (it was introduced in the Geoff video at the beginning of the day). To introduce RICk radar and the RICk tips (guidelines). This slide is animated T: What do you know about RICk; where do you capture this? How do you capture readiness? We ask about Stages of Change, don’t talk about this. Ask readiness on a continuum Your readiness can change throughout a consult depending on what you’re talking about (Slide 38) We have already started to discuss RICk and how it applies to a consultation, in the case of Geoff in the video this morning, but now lets discuss why we have RICk as a principle. The RICk principle acts as a decision tool to systematically work with a client’s readiness, importance and confidence and knowledge (understanding) and consider how these might be impacting on their desire and ability to take action. All of these factors interact with each other. Readiness also has a timing aspect to it. (G26)

check knowledge, build motivation, raise priority
RICk tips If importance is low: If confidence is low: check knowledge, build motivation, raise priority identify and address barriers P: To introduce the RICk tips This slide is animated T: So, if Importance is low, what do we need to do? Repeat for C. (See slide animation to hide the answers until this is completed). I - If importance is low don’t drop below the decision line C - If confidence is low then you may need to work on small steps and reign the patient in from making changes that are too big These factors are not independent. By raising someone’s importance, this will often increase confidence as well. By raising someone’s confidence, it may increase their importance. Both impact positively on readiness Invite participants to complete the relevant question on their PP and ET self-appraisal form PP - e and f (G26)

First ask the client, Then offer:
Assessment Clinical education Health recommendations Treatment and referral options Strategies to achieve goals Suggestions regarding possible barriers P: To introduce and explain the principle This slide is animated T: This principle is about the way we provide information that can work for us or against us. The first ask, then offer principle encourages clinicians to ask clients for their input before offering education, information or strategies for action. By asking a client first, a clinician is able to gauge how much the client already knows and, therefore, provide more tailored information rather than global education or advice. Doing this respects the client’s pre-existing knowledge and experience and helps to facilitate client choice and control. The first ask, then offer principle recognises that clients are the experts in their own lives and encourages the expectation that each client is an active participant in the process of improving their health. It also reduces resistance, lessens the likelihood of a clinician receiving a ‘Yes, but’ response and allows clinicians to build stronger rapport with their clients. When clients are able to generate their own solutions, it builds their confidence and promotes their belief in their ability to solve their own problems. When additional information and advice is provided by clinicians, it is offered in a menu of options wherever possible, so that it doesn’t undermine a client’s autonomy. Mention the client first and menu of options techniques to be covered in the next section that help you to use this principle in practice. Invite participants to complete the relevant question on their PP and ET self-appraisal form The benefits of this principle for clients and clinicians include: Saving time as you don’t need to tell the client what they already know The clinician can clarify any misinformation The clinician can provide target education The patient feels listened to and that they are being treated as part of a collaborative process that builds rapport How do you implement this principle in a consultation? You would use the Ets: Client First and Menu of Options PP - g (G29)

WAIT til 8 Why Am I Talking? Why Am I Taking Notes or Typing?
P: to introduce and explain the principle This slide is animated T: People often need time to think and respond to our questions. How does this principle change the nature of our consultations? If we don’t give them enough time, this can be problematic for a number of reasons. Workshop: What are the potential problems? Bring out the following points: you end up telling people things they already know and this can mean that they switch off or resent the information and you don’t find out what information they already have so you miss the opportunity to deliver targeted information – and save time The client disengages from the conversation, therefore the clinician inadvertently takes responsibility it can damage rapport HCA did some casual research and discovered that people commonly respond at about the 8 second mark. WAIT til 8 is both a communication principle and a technique. This is just a general rule and does not need to be applied to all clients or in all situations. Video - Greg: Providing suggestions – 90 secs T: I am now going to put on a short video that highlights some of these issues. What did you think? Which practice principles weren’t used? Invite participants to complete the relevant question on their PP and ET self-appraisal form People often need time to think and answer A response at the 8 second mark is common PP - h (G29) WAIT til 8 video

Invite the client to write
Why might this increase a client’s success rate? P: To introduce and explain the principle T: Why would we invite the client to write down plans for themselves? Workshop: We know that many clients struggle with reading and writing, so we’ll discuss other options if literacy is an issue in a little while. However, Who does this already with their clients? Some research shows that a client’s likelihood of success is increased up to 10 times if they write their own goals, action plans, and points in a consultation. Why would that be? [Memory, ownership, learning process, engagement, in their own words, in their own hand writing - they can read it, etc]. Example of a client writing own notes: a physio’s client just wrote ‘rotisserie chicken’ to remind herself of the concept of frequently changing posture with acute back pain. Would anyone feel uncomfortable about asking the client to write? Here is an example of how it might look (play video) Greg video: invite the client to write – 25 seconds Invite participants to complete the relevant question on their PP and ET self-appraisal form PP - i (G30) Invite to write video

Working with low literacy
Use visual tools Ask clients how they usually remember Visual and auditory memory aides Tactile tracking strategies (marbles/buttons/strokes of a pen) Rehearse action plans verbally P: To acknowledge and highlight some strategies to use with clients with low literacy This slide is animated T: You already adapt your consultation style for your different clients. We know that about 30% in the general population and up to 50% in some areas have problems with literacy. Who works with clients with low literacy? How do you work with clients who have are not comfortable with reading and writing? Here are some other ideas on how to work with clients with low literacy. Note that low literacy doesn’t mean no literacy WS: Does anyone have an example of one of these you have used with success?

Working through interpreters
Invite interpreters to brief you on culture Brief interpreters on your practice style Learn how to say hello, goodbye, yes and no in each language. Use as little speech as possible Promote client choice - use visual tools Break dialogue into small chunks – to avoid interpreters summarising and oversimplifying Ask clients to paraphrase information to check accuracy Use appropriate eye contact Allow extra time P: To acknowledge and highlight some strategies to use when working through interpreters This slide is animated T: You’ll also need to adapt your consultations when working with interpreters. Who works with interpreters for their CALD (culturally and linguistically diverse) clients? What tips do you have for working with interpreters, and making these consultations effective? (click to show detail) Here are some other ideas on how to work with interpreters. Points to consider: Ensure that you know the client’s dialect before booking an interpreter e.g. there are 23 different Arabic dialects Remind the client that you are the clinician not the interpreter Debrief pre- and post-appointment with the interpreter

Working with cognitive impairment
Identify who the decision-maker is Work with the client and/or carers Work with patient idiosyncrasies, likes and dislikes Incorporate reminders/visual cues and aids to comprehension Adapt pace and style of language to client Check comprehension P: To acknowledge and highlight some strategies to use when working with clients with cognitive impairment This slide is animated T: Who works with clients with cognitive issues? What sorts of issues? (Dementia, memory, intellectual disability, severe mental illness that affects ability to rationalise, limited decision-making ability, etc.) How might you adapt your approach if a client has cognitive impairment? If a person can’t communicate with you due to cognitive impairment, you can’t health coach them. Who would you work with? It might be more appropriate to work with their carers or with both client and carer. The question you want to keep in mind is, who is the decision maker? (click to show detail) Here are some other ideas on how to work with clients who are cognitively impaired.

Clients Adapt the HCA approach to suit your clients! Cognitive
Passive Compliance ? Acute/Chronic Health Issues ? Language/ Lit. Issues ? Cognitive Impairment ? Cultural Psychosocial Resistance ? Depression Anxiety ? Age-Related Adapt the HCA approach to suit your clients! Clients P: To acknowledge that people have many different issues so a clinician’s approach needs to be tailored regardless of whether they use the HCA approach or not. T: So as you can see, your clients come in with all of these types of issues that require us to change the our approach to best suit their needs. You will all be adapting your conversation style already to deal with different types of clients with different issues such as the ones on the slide. The behaviour change principles apply to all people, however the way that we say things needs to be adapted to suit the individual. We also need to keep in mind that different people will have different motivators as already discussed.

When you don’t succeed…
Trial & error When you don’t succeed… ...try a different strategy! P: To introduce and explain the principle This slide is animated T: A final principle involves normalising the difficulty of taking and sustaining action to improve health outcomes and encouraging clients to take a trial and error approach. If you discuss trial and error with your clients it increases the likelihood that they will attend review sessions. So what do you think the affect will be on the client if you discuss trial and errror? It includes consideration of concepts and strategies associated with relapse prevention. The trial and error principle helps clients to recognise the need to change their strategies when they are not working, and to do this without engaging in self-blame. Workshopping: (Use slide animation. Put up “When you don’t succeed…” and then ask participants to finish the statement). So when at first you don’t succeed, what do you do? (When people say “try, try again”, challenge them gently – is that what you want clients to do? Keep trying if it doesn’t work?) We’ve all seen clients who have been trying and trying again without success. So what do we want them to do instead? We want them to try a different strategy! How do your clients react when you apply this principle and foster a trial & error approach? It generally leads to a sense of relief, and increases the chance that patients will come back, because otherwise they may think that you expect them to do things perfectly. Video - Greg trial and error – 30 seconds P: This is a short clip illustrating how you can integrate the trial & error principle into your consultations. Invite participants to complete the relevant question on their PP and ET self-appraisal form Outro: To wrap up the practice principle section, I’ll hand you back to X PP - j (G30) Trial and error video

Teach a man to fish… Derek
P: To wrap up the practice principles section with a proverb and a case example (Derek) and tie the principles in together T: Building patient behaviour change and self-management skills means that we are ‘teaching people how to fish’. Ask: do you know the Chinese proverb: give a man a fish he’ll eat for a day. Teach a man to fish and he’ll eat for a life time? This encourages our clients to take responsibility and self manage. It can also be a simple way to describe your role to a client. Let’s have a look at a case example to see how some of the practice principles tie in together to help clients to self-manage Click the link to open the Derek case (slide 158) After discussing the case, click the link on slide 163 to return to this slide Invite participants to review their PP and ET self-appraisal form. Ask them to identify and tick their top three strengths. Then ask them to identify and circle three that they think they would benefit from working on. Derek

HCA essential techniques
Section 3: HCA essential techniques T: This section of the workshop reviews the essential techniques that you need to know in order to facilitate behaviour change in your clients. Some of the techniques you would use with every client and some of them you would only use when you needed to identify and address certain barriers to action. Orient participants to the diagram on the inside cover of Section 3 of the Guide. (G inside Section 3 tab)

Are you ready to do something about your own health?
4. Planning 3. Decision & Commitment 2. Motivation & Expectations 1. Knowledge & Understanding P: To provide an opportunity to experience a number of essential techniques in the context of the participant’s own health behaviours and to practise and the client first technique. T: In a few minutes we are going to do our first pairs exercise, to practise the client first technique. The client first technique is a high readiness technique that you can use to help to build a client’s confidence in carrying out certain tasks or actions. So before we do the exercise I will help you to select something that you are ready to work on to benefit your own health. In other words, this is a below the line technique. Firstly I will invite you to choose a health area to work on and then explore your motivation. Before we go into goal setting, we are going to look at whether you have made a decision to take action on this issue or not (if not, you can select a different issue to work on). Then you will set a personal goal and create an action plan by co-coaching in pairs. Relate the above processes to the first four sections of the generic behaviour change pathway on the slide. You can use the same approach in any education groups that you run (but without the PowerPoint slides). Decision Line

Knowledge & understanding: What can you do to be healthier
Knowledge & understanding: What can you do to be healthier? Consider your own clinical indicators & risk factors: ZZZZZ… Other? Health Checks? P: To allow participants to choose a health issue to work on and to provide an example of a tool that can be used in groups or consultations to help clients to select relevant general health categories to work on. T: Because we are not currently in a clinical consultation, we have selected a tool with general lifestyle behaviours on it. In many consultations with specific clinical aims this tool would not be appropriate and you would be helping the client to prioritise what they needed to do. Explain what the pictures represent Cardiovascular exercise or social engagement Increase healthy foods or increase fibre Osteoporosis, injury rehabilitation or musculoskeletal issues Cut out or cut down on alcohol or high energy beverages/hydration Clock: time or stress management Resistance training Quit or reduce smoking Balance or flexibility/ relaxation Reduce saturated fat or takeaway food/reduce unhealthy options Medications or supplements Sleep or energy management Weight management I’d now like you all to circle one health category that you are ready to work on.

Motivation & expectations: readiness
How ready are you to work on this issue today, given all the other things that you are already doing? Some optional ways to answer: 1. Draw a line and place a cross on it; 2. Pick a number out of 10; or 3. Rate as low, medium, or high X T: Now we are going to look at how motivated you are to take action in the lifestyle category that you have chosen by asking RICk. In relation to the goal that you have just chosen, how ready are you to work on this today? There are many ways you can rate readiness, after all it is not a ‘one size fits all’ solution! You might prefer to use numbers or categories e.g. low, medium or high or draw a line and mark where you are in readiness. Write down your readiness level or hold it in your mind.

Motivation & expectations: importance
How important is it to you personally to work on this issue (given all the other priorities currently in your life)? Some optional ways to answer: 1. Draw a line and place a cross on it; 2. Pick a number out of 10; or 3. Rate as low, medium, or high X T: If you ask people “how important is exercise?”, for example, everyone knows that exercise is important so they will often rate it as highly important. But they may not think that it is important for them to do exercise. (Ask an easy question, you’ll get an easy answer). The trick is to ask “how important is it for you personally to start (or increase) exercising, given everything going on in your life right now?” This will often get you a very different, and more accurate, answer. With this in mind, rate your personal importance in doing something about your chosen issue.

Motivation & expectations: confidence
How confident are you that you will make some manageable and sustainable behaviour changes in relation to this issue? Some optional ways to answer: 1. Draw a line and place a cross on it; 2. Pick a number out of 10; or 3. Rate as low, medium, or high X T: How confident are you that you can make some manageable and sustainable changes in your chosen health category/area? Take the time now to consider your confidence in taking action.

Decision & commitment In relation to your chosen health issue consider... If you continue to do what you are currently doing (or not doing), what will the long-term consequences be for you? What about the people or things that are important to you? If you do make some manageable and gradual changes, what immediate or long-term benefits would you expect to gain? What would the impact of this be? Do these expected negative or positive outcomes make it important enough for you to work on this issue now? T: Making a decision is not always easy, particularly when life can get in the way. Now we can consider your decision-making and commitment to taking action in your chosen area. (point to generic behaviour change pathway) This slide is animated to allow time for consideration of the questions Read out the questions and prompt participants to write points down if desired. Allow time for participants to think and write. Do these expected negative or positive outcomes make it important enough for you to want to work on this issue? How do we know?

Did your RICk levels change?
Decision & commitment Are you ready to do something about this? Is it relatively important to you? Are you confident that you will take some action? Do you have all the information you need to make a decision and take action? T: Let’s ask RICk again to see if any of your RICk levels changed as a result of reflecting on this issue. Invite participants to rate their RICk levels again. Ask: Do you have the knowledge required to take action or do you need extra information? Ask if their RIC levels increased or decreased You should all now know your RICk profile for your chosen health category. If your readiness to work on your selected issue is low after all, pick another topic to work on because we are now getting into goal setting and action planning and you need a certain amount of readiness to do this. Did your RICk levels change?

Planning: create a wish list of possible options for pursuing your health aims
Write down at least 6 or more different ways that you could take action in the lifestyle or treatment category that you selected Think of this as a wish list: for the time being ignore any barriers that might come to mind for any of the options you consider Try to include some options that you have not tried before T: Now that we have dropped below the decision line, we can engage in some planning processes In relation to the topic that you have chosen, I’d like to invite you to create a list of at least 6 different ways that you could to take action in this general health area in order to get better outcomes. Ignore the barriers for the time being and think of this as a wish list. For example, if your goal was stress-management, you might list: leaving work earlier; have more personal time; doing yoga or other activities; taking time to read a book regularly; discussing the state of the house with your family etc. I’ll give you a moment to consider what are your options. Outro: I’ll hand over to X to introduce you to the technique and take you through a practical exercise

The client first technique
Elicit information from the client prior to offering your own education and suggestions: What do they already know? What are they already doing? What would work for them? What could they do to address a particular barrier? P: To introduce the technique and provide the rationale This slide is animated T: The technique you are about to practice operationalises the principle “first ask then offer”, which increases patient engagement and decreases resistance. Generally clinicians are trained to ‘tell’ rather than ask. This technique is simply stopping and asking the client for their ideas and input, and reflecting back to them to gain confirmation of what the client is thinking, so that we can elicit this (indicate dot points on slide) This is the technique you will practise in this exercise. (G33)

The HCA client first technique High readiness technique to do planning & increase confidence
Person 1 – The clinician Use reflection, summarising and questioning Provide NO suggestions or advice for this exercise Guide partner toward creating a goal and an action plan Use prompt questions Respect confidentiality Person 2 – The client Choose a REAL change that you are very ready to work on from the options list you created Avoid story telling! (10 mins each – we will tell you when to swap) Write down your personal goal and action plan (handout) Give your partner a big cheery “yes but” if they give suggestions! P: To introduce and practice the client first technique This slide is animated T: This exercise is a chance for you to practise this technique – where are we in the HCA generic behaviour change pathway (relate back to pathway). Now we are going to use the client first technique to coach each other to come up with a personal goal and action plan. This technique looks slightly different above and below the line. The way you’re about to do it is a below the line application. Part 1 –Instruct participants to find the copies of these instruction slides in their handouts and orient them to the relevant page in the Guide, pages Part 2 – Describe clinician role. We are going to set some challenges for you when you are in the clinician role. You are going to practise using the WAIT til 8 principle. For this exercise only, we are going to ask you not to give ANY advice or suggestions whatsoever. After all, we as health professionals are very good at giving advice. So this exercise takes you to the other end of the spectrum where you are not to give any advice, none at all! Part 3 – Describe client role. Key points to make: This is not a role play – role plays don’t work using these techniques and make it harder for your partner to use the techniques Pair up participants Clock each session for 10 minutes, shave time off this is most of the participants finish early. 8 minutes is often enough time for participants to practise the client first technique. 69

Optional prompt questions for client first technique
Which health aspect would it benefit you to work on? How ready are you to work on this health area with me today? What are you currently doing regarding this issue? What benefits do you expect to achieve? From the list of options that you wrote down, which of these options might work for you now? What personal goal could you set for yourself? What actions would you need to take to achieve this goal, step by step? What else?... What else? Would it help to write these steps down to remember them? What might get in the way and what could you do about it? How confident are you that you will achieve this personal goal? T: These prompt questions are a guide only. Please do not treat them as a check list that has to be read verbatim. Change the language to suit your client (e.g. not ‘barriers’, but what might get in the way). Attract our attention if you need assistance. Leave this slide up on the screen as the participants complete the exercise (G33)

Was it difficult to refrain from jumping in with your own solution?
How did you go? Was it difficult to refrain from jumping in with your own solution? What was it like being the client? What was it like being the clinician? T: What would you like to say about doing that exercise? What was it like in the client role? Did you feel you were being listened to? What was it like in the clinician role? Who found it difficult not to give their own solutions? Acknowledge that it is human nature to want to provide solutions but this inhibits patients coming up with solutions that will work for them. It is something that we all need to continually work on. Ask who experienced a ‘light bulb’ moment. Point to generic behaviour change pathway to show how the exercise just took participants through the AL/BL processes. Prompt participants to complete the client first question in their PP and ET self-appraisal form. ET - a 71

How do you offer suggestions & avoid “yes, but…” ?
P: To acknowledge that not all clients will be able to think of their own solutions and to introduce the menu of options technique This slide is animated T: Do you think that all clients will be able to think of their own solutions to problems? Or do you have any clients who would say, “I don’t know, you tell me!” Given that many clients will have problems coming up with their own ideas, how do you offer suggestions, but avoid getting a “yes, but…” response? Imagine if you went to a restaurant where the waiter says “I think you should have the steak tonight”. How would you react? Now consider what usually happens. You sit down, the waiter recommends the steak and leaves you with the menu to decide. Are you more likely to consider the steak? This avoids the “yes – but” The solution is to offer a menu of options, but in a way that avoids the “yes, but” response. We are trained from a young age to choose from a menu, so even when there is a limited consideration set we will pick something and feel that we have choice. How does this relate to our clients? (It provides clients with choice and decreases resistance). Using the menu of options approach is also a good way to educate clients about the things they could do to improve their health that they might not have thought about. The menu approach can also be used when discussing barriers. How many of our clients are aware of what gets in the way for them? Offering a menu of barriers is also useful because it is not a ‘one size fits all’ when it comes to what blocks a person from taking action. Offer a menu of options! Behind every “yes, but” is a barrier (G35)

Offering a menu of options:
Use a lead-in explanation Ask permission Provide multiple strategies where possible Invite the client to think of something else that may suit them better Ask the client if they think any of the ideas might be suitable P: To provide instructions for offering a menu of options T: It is essential for clinicians to be able to provide options and suggestions to clients. The menu of options technique is used to do this without creating resistance. These are the steps for offering a menu of options: Use a lead in statement and ask permission. For example: “If you like, I have some suggestions that I can give you, but they may or may not work for you. Would you like to hear them? You could do A, B, C, D or E, or is there anything else that you can think?” Don’t forget that the menu of options needs to be tailored to your client. It is essential for clinicians to be able to provide suggestions to clients. The menu of options technique is used to do this without creating resistance. Prompt participants to complete the menu of options question in their PP and ET self-appraisal form. ET - b (G35)

Using your RICk radar Client First Observe body language, tone of voice and other verbal and non-verbal cues to pick up low RICk or ambivalence P: To discuss the concept of using your RICk radar This slide is animated T: A lot of the time you don’t need to ask RICk openly, you can easily pick up cues about a client’s RICk levels from what they say and from their body language, tone of voice and other cues. (It’s not only about asking questions, but also about listening, reflecting and summarising the clients’ responses.) How does using your RICk radar help us as clinicians? What is ambivalence? See definition in Guide glossary. Prompt participants to complete the RICk radar question in their PP and ET self-appraisal form. ET - c (G38 & Glossary)

Client case demonstration
Video - Peter The potential pitfalls of scaling questions P: To highlight the dangers of using complex scaling questions. T: How do you ask scaling questions in a way that doesn’t put people off? System requires numbers – this is why I’m pushing you for the numbers….. (feel like you’ll listening do….) T: This next client video showcases some potential pitfalls of scaling questions. A technique that is commonly taught in MI and SFC courses involves asking complex scaling questions with two sets of numbers in them. Have a look at how Peter reacts to this. Video - Peter: scaling questions – 3.5 mins In part 1 - Peter made an assumption about what the interviewer was asking and hence didn’t answer the question correctly. What did Peter think the clinician was asking? In part 2 - You can see that Peter was able to response much more easily when he was asked about the importance of the benefits that he hoped to get out of exercising. This was more relevant to him. The key purpose in the debrief is to work with the participant’s criticism of the video and to show why we need to adapt our style to what is appropriate for the client, and not to ask RICk in an overly formal & rigid way (this will build resistance rather than overcome it) versus flexible application. Outro: I’ll hand you back to X to start discussing how we can help someone cross the decision line Peter video

How many different ways can you think of to ask RICk?
Asking RICk Small group exercise: How many different ways can you think of to ask RICk? P: To highlight that there are many ways to ask RICk and that a conversational approach is usually the best method. It is not necessary to ask scaling questions unless you need to collect quantitative RICk data (e.g. for research). This slide is animated T: If in doubt, ask RICk There are many different ways to do this, and you need to tailor your questions so that the language is appropriate and you don’t sound like you are repeating yourself all the time. In your workbooks on page 38 there is an extensive list of ideas on how to do this. Take a moment now to read through the list and highlight any that you like. Discuss with your partners phrasing that you would use with your clients. Points to bring out in discussion: The readiness question relates to timing. The importance question relates to motivation, having a reason and to competing priorities. This is the main focus above the decision line. The confidence relates to difficulty, manageability or the presence of barriers. This is the main focus below the decision line. How else could you phrase these questions for your typical clients? R, I, C We know that scaling questions won’t suit many of your clients, and so using this approach with everyone is not only inappropriate, but will build resistance. We will look at some other ways to ask RICk in a moment, but now we’ll show you a video of what it might look like if we ask RICk in a complicated way. Invite participants to look at the alternative ways to ask RICk in their manuals. Ask them to reflect on these examples and to mention and comment on any that they have used and highlight/tick the ones that they like. And/or write in Write your own words sections, page 43 on the Guide. Workshop: Exercise – write your own menu of RICk options small group exercise This is an opportunity to workshop different ways of asking RICk and to give participants an opportunity to write in their own words. Think about your clients and how you would ask these questions in ‘plain English’. How would you ask readiness? What are some different ways of asking importance? What about confidence? Invite participants to write in their own words in the Guide section for Step 3. Additional notes: If appropriate, mention how to work with interpreters using RICk and explain to the interpreter why you’re asking these questions. Prompt participants to complete the ask RICk question in their PP and ET self-appraisal form. ET - d (G37-39)

Common above the line thinking barriers
} I have a problem The problem is serious enough to consider action It could adversely affect things or people that are important to me Weigh up expected costs and benefits Decide to take action or not There is an effective course of action open to me P: To introduce the notion that people make decisions by weighing up the pros and cons (decisional balance) and that certain beliefs will affect whether or not the pros will outweigh the cons. Knowing this can help us to help clients to make sound decisions. This slide is animated T: The common above the line barriers are related to thinking barriers. These barriers also come in the form of beliefs. Patients will only decide to take action or not if they believe the following: Box 1: The person has to believe that there is a problem. For example, if a person is told they are at risk of getting diabetes, however no-one else in their family has diabetes, they might think they won’t get diabetes and so are unlikely to take preventive action. Box 2: The problem is serious enough to consider action. If they believe that diabetes is “just a touch of sugar” are they likely to take action? Box 3: It could adversely affect things or people that are important to me. If people don’t believe that the consequences are serious are they likely to self manage? Box 4: There is an effective course of action open to me. If they don’t believe, for example, that taking action will have an effect, e.g. increasing exercise will improve their BGLs, then they are unlikely to take action. Box 5: I am able to pursue this course of action. Their confidence or self-efficacy (belief that they can) will also influence the decision. Box 6: I can’t put off making a decision. I have to take action now. (Click to display bracket + box) All these beliefs feed into and impact on how the client weighs up the pros and cons in taking action or not (click to show arrow + final box). We’ll have a look at a way to aid this decision in a little while, because if the client perceives that the tradeoffs outweigh the potential benefits of change, they won’t make that effort. This ties into Motivation & expectations (HCA generic behaviour change pathway) This also relates to a decision to go to a program (e.g. cardiac rehab program), or take up a referral to a health practitioner. I am able to pursue this course of action I can’t put off making a decision Adapted from the Health Belief Model (Becker & Rosenstock, 1984)

Beware the Motivation Trap!
≠ Motivation to reduce pain lose weight retain independence etc. Motivation to engage in actions or tasks required to reduce pain, lose weight, retain independence etc. P: To introduce the idea of the motivation trap – that people are often motivated to gain long term outcomes, but are not necessarily motivated to do the things necessary to attain the outcomes. T: When someone really wants an outcome like reducing their pain, maintaining their independence or losing weight, does it necessarily follow that they are motivated to take the necessary actions to achieve those outcomes? To make the point you can ask the participants how many of them would like to double their income. Then ask how many are motivated to work twice as many hours or to go back to university to retrain so that they can earn a higher salary. (G27)

Understanding importance Why do people say an issue is important when really they are still above the decision line? Expected responses: playing the patient role or pleasing you Intellectualised responses: something I feel I ‘should’ do Wanting outcomes: but not prepared to take the actions required to get the outcomes P: The motivation trap T: Why do people say something is important when really they haven’t made a decision or committed to taking action? Read from slide and workshop / reflect any of the Ps responses.

Signs of shaky commitment (ambivalence)
Body language or tone of voice contradict RICk responses Statements like ‘I know I should…, but, ….’ Laughing nervously when talking about a topic Strong emotion when discussing condition/s , lifestyle/treatment categories or goals and actions Weak reasons to take action & strong reasons not to Changing the subject during discussion Others? P: to ensure that the participants understand the concept of ambivalence T: We just discussed the motivation trap and talked about how critical it is for clients to believe that the pros will outweigh the cons in making a decision to take action. Often this doesn’t happen. We get stuck in this process and can’t make a decision to take action because we are in two minds about the matter. There are reasons for taking action and reasons for not taking action. This name for this state is ‘ambivalence’. But if this is not a term that you are familiar or comfortable with, you can think of it as ‘being on the fence’ about a decision. Ambivalence reduces readiness to change by impacting on importance and confidence. Ambivalence can lower a client’s readiness, importance and/or confidence. The main thing to understand is that when a client is thinking or feeling like this, they will be focusing on the barriers to change and will be unlikely to take and sustain action. Fortunately, there is something that we can do to help them to decide one way or the other. This is called ‘resolving the ambivalence’ in the motivational interviewing literature. We use a technique called decisional balance to do this. Workshopping options: Would anyone like to explain in their own words what ambivalence is? Can you think of your own situation when you have procrastinated because you were stuck in this thinking pattern? Ask: If you hear a patient say, I know I need to monitor my blood sugars daily, but I feel fine, what does your RICk radar tell you? What happens if we then tell them why they need to test regularly? How do we get the message across without arguing with logic and creating resistance? [This gets participants thinking about their own patients] What other verbal cues would indicate that a patient is two minds? [Typical usual responses are things like: I should have a shower but the nurse can do it; I know I need to move more but I’m too tired etc. (G26)

Exploring the tradeoffs to increase importance
Smoking Quitting Pros P: To help clinicians to recognise that there are four aspects to a decision that need to be explored, but often clinicians and clients are talking at cross purposes (focusing on different quadrants). This slide is animated - start with only the vertical line showing with smoking and quitting on either side. T: Making health changes is often not an easy choice because there are trade-offs that need to be made on both sides of a decision. Let’s take smoking as an example. Ask: When we talk to clients, what do we tell them are the implications of smoking? Get all the answers (e.g. all of the bad things). Ask: What do we tell them about quitting? Workshop this (e.g. all the good things). Ask: People smoke for a reason. What’s good about smoking? Ask: What is not so good about quitting? In other words, there are positives and negatives of smoking, and positives and negatives of quitting. So it’s not just all bad for smoking and good for quitting. Use slide animation to make the point. Note: If participants spontaneously come up with positives of smoking and negatives of quitting – acknowledge how cluey they are for understanding that smoking is not all negative and quitting is not all positive. So what’s good about smoking? I put it to you that its a really positive behaviour. Use smoking scenario: You think about it, you’re on the phone, the boss is giving you an earful, so you grab your ciggies and head outside into the sunlight. All your friends are out there, debriefing about what happened. What’s wrong with that? You have removed yourself from a stressful environment and getting some sunshine – vitamin D absorption and stimulating serotonin. (drag), “Ah, that's good!” (have another drag). The only thing that was bad is that you lit the cigarette and sucked in chemicals. In other words, there are positives and negatives of smoking, and positives and negatives of quitting. So it’s not just all bad, bad, bad and good, good, good. Ask: When clients are ambivalent, which two categories are they focusing on? (pros of smoking, cons of quitting) Where do we as well intentioned health professionals try and convince our clients to focus on (argue with logic)? (cons of smoking, pros of quitting). So we’re talking at cross purposes a lot of the time. What effect does this have? Builds resistance and affects rapport. In order for someone to make an informed conscious decision, they need to consider all 4 perspectives. Clinicians also need to consider all four perspectives and acknowledge the difficulty of change and why people continue to do what they do. Cons

Decisional balance framework
Take no action Take action Good Outcomes 1. Barriers to taking action 3. Benefits of Not so Good Outcomes 2. Negative consequences of not taking action 4. P: Introduce conceptual framework T: Who’s familiar with the decisional balance framework? DB is not a tool, it’s a natural process we go all through when we make decisions. We weigh up the pros and cons in our heads. When we are ambivalent about taking action, it is often because we tend to shortcut the process and focus mainly on the barriers to action, rather than looking at the whole picture. Asking decisional balance questions can provide a systematic way to help clients consider all the pros and cons in order to bring them closer to making a decision. In order to increase importance the client needs to identify an intrinsic motivator by exploring the benefits and consequences. What is your understanding of an intrinsic motivator? (personal, autonomous reasons) However, it is not just a case of simply telling the client the benefits and consequences. What may happen if you do this? (potentially create more resistance or the client will switch off). It is the client who needs to identify personally meaningful benefits and consequences that result from the clinical benefits and consequences. The technique you use to help the client identify an intrinsic motivator is called ‘digging down’ (known in CBT as ‘laddering’). As you can see, working in quadrants 1 and 4 can increase confidence by helping the client to address some of the barriers. Working on quadrants 2 and 3 increases importance. Let’s look at an example Additional notes: The decisional-balance framework allows clinician and client to: identify the main barriers to taking action (behaviours, emotions, situations, thinking), identify and address knowledge gaps regarding health conditions, consequences of inaction and benefits of action, and identify intrinsic motivators for action. Focus on quadrants 2 & 3 to  importance Focus on quadrants 1 & 4 to  confidence (G45)

Video - Justine Decisional balance assistance for smoking Things to consider: Why did the clinician ask DB questions? Which DB questions were asked? What were the pros/cons of smoking and quitting for this client? Video – Justine smoking: 15 minutes P: To provide an example of the DB technique in action. The video shows that the technique is delivered in a conversational way (without the use of pen and paper tools). T: You’ll hear decisional balance assistance being delivered in a natural conversational flow – be aware that the video is quite long compared to the other clips that we have shown. But that is sometimes how long it takes for a client to explore an issue. Task whilst watching the video: Flick up slide 79 and advise participants to write a similar cross on a piece of paper with the same headings Invite them to fill out the issues for Justine as they watch the video After the video, you can see how much detail they picked up on After the video - workshop: Ask: Does anyone have clients like Justine? Acknowledge how it’s a little ‘all over the show’, but often this is what is going on for our clients and they need to think their situations / conditions through. Which decisional balance questions were asked? Notice that question 1 was not specifically asked, but a reflection was offered that showed understanding of the client’s reasons for smoking. What were the client’s readiness and importance levels? She said that she was over 100% ready and importance 9/10. But what were the indicators that the clinician should still go into DB? Why wouldn’t you go below the decision line straight away with this client? What question helped the clinician to discover what has stopped the client before – what has caused the client to return to smoking in the past? Justine video

Justine: quitting viewed as negative
The decision: Will I quit smoking or not? Continue smoking Quit smoking Good Outcomes It is social – something I do with friends and partner I enjoy it I don’t get bored It gives me a time out - relaxation Healthy skin Look better Feel better Smell better Not so Good Outcomes Wheezing, coughing My skin not so good and will get worse as I age Be seen as selfish – letting my friends down Lose my partner in crime – impact on my relationship Judged as a failure ‘here we go again’ P: To help the participants to analyse what was going on in the video and to make the connection that when a person decides not to take action it is because they have reasons not to. This slide is animated Workshop: What were the pros and cons of smoking and quitting for Justine at the start? Click to show DB table. This is how Justine’s profile would have looked to start off with. It is typical of a smoker who has decided not to take action at this point in time to quit smoking. Where are the Justine’s intrinsic motivators? [in the barriers quadrants] This suggests that she starts out strongly motivated not to quit, even though she knows there would be some benefits. The barriers are too great.

Justine: quitting viewed as positive
The decision: Will I quit smoking or not? Continue smoking Quit smoking Good Outcomes It is social – something to do with friends and partner I enjoy it I don’t get bored It gives me a time out - relaxation My skin will have a ‘glow’ I will look better, smell better, feel better Confidence Won’t be judged as a ‘smoker’ I will not be labelled with having a ‘dirty habit’ Greater social acceptance Not so Good Outcomes Wheezing, coughing My skin not so good – will get worse, smokers lips etc. I struggle paddling out It is stopping me from doing sports that I enjoy – my fitness is bad It is inhibiting me I am losing friendships with non-smoking friends Be seen as selfish (but actually my friends will accept this change and support me) Expectation that I am a smoker (but I can change this) Lose my partner in crime (but he will support me if I am serious about it) Judged as a failure ‘here we go again’ (it takes a number of attempts to quit) P: To help the participants to analyse what was going on in the video and to show how the process of assisted decisional balance can change the person’s profile so that the intrinsic motivators shift into the benefits of action and/or the consequences of inaction. In this case, Justine was able to re-frame the way she thought about a barrier, so that its strength as a barrier lessened. This slide is animated Workshop: What were the additional pros and cons of smoking and quitting for Justine at the end? Click to show DB table This is how Justine’s profile looked at the end. It is representative of a smoker who has decided to take action at this point in time to quit smoking. Note that she has started to “yes but” her own barriers. This is a common occurrence when people start to shift their motivation towards wanting to take action. ‘When I hear myself speak, I learn what I believe’.

Digging down in the benefits: Should I give up smoking?
I will look better and not wheeze I’ll feel better I’ll be able to be more active (body boarding) I want to be able to keep enjoying life as I get older (and this won’t happen if I don’t give up before I get older) * Therefore, I want to give up now P: To introduce the notion of ‘digging down’ to help a client to identify an intrinsic motivator, and to provide an example of ‘digging down’ in the benefits This slide is animated T: By using what we call ‘digging down’ techniques you enable the client to think about the true consequence of change, for themselves and the things that are important to them, both now and in the future. Walk through the example and demonstrate the technique using the slide animation (What’s the problem with the statement: “I will look better and not wheeze?”) it’s not that clear / ambiguous  so what would be good about that / what impact would that have?  etc…. Point out that without using ‘digging down’ techniques during decisional balance, often a client won’t identify a strong motivator and may, therefore, not decide to change/take action How can you tell when a client has made an important connection? What do you see or hear? (G49) * Intrinsic motivator

Digging down in the consequences: Should I go to bed earlier or not?
I will be tired in the morning I’ll have a worse start to the day (less organised/feel worse) I’ll have a worse day at work (less productive, more grumpy) I’ll get home in a bad mood I’ll be grumpy at home and likely to fight with my wife * P: To provide an example of ‘digging down’ in the consequences to find intrinsic motivator. This is an example that many participants should relate to personally. This slide is animated T: Digging down techniques can be used in relation to the benefits of change/action, or in relation to the consequence of not taking any action. This person was ambivalent about going to bed earlier. Walk through the example and demonstrate the technique using the slide animation Ask: who can relate to this example? How might it look different for you? * Intrinsic motivator

Conceptual framework for decisional balance
Alternative A Alternative B Good Outcomes 1. Acknowledge reasons for current behaviours (barriers) 3. Identify possible benefits to be gained from taking action Not so Good Outcomes 2. negative consequences of inaction 4. Acknowledge undesirable aspects of taking action T: This is one prompt sheet that you can use to remind you of the decisional balance questions. You can see that the questions are numbered in order. Why would you start off with the question, “What’s working for you now?” (Question 1) (Acknowledging that there are things they like or get out of what they are currently doing leads to decreased resistance because it shows you understand). The purpose of this slide is to explain how to do decisional balance and demonstrate using an example worked with the group. What’s an issue you’d like to look at that relates to your own client base? Workshop the example. Give the client a name and some demographics prior to starting. Use the Examples hyperlink on the slide to attach and talk through actual client examples. Does this sound a bit complex for some patients? Choose 1-2 decisional balance examples that relates to the group. Workshopping point when going through examples: Will clients always know about the benefits and consequences? How do you inform them in a client centred way? (Ask permission, outline a ‘menu’ of health consequences/benefits. It is important to then ask the client how this would impact on them personally (digging down to help them make a connection to a personal level). Note: If participants only work with elderly clients e.g. OTs and PNs, use the ‘ramps’ example, ‘selling house vs. moving into a retirement village’ examples and/or the 84 year old elderly lady case. Is anything you have mentioned important enough for you to want to work on this? (G45)

Decisional balance - pairs exercise
Talk each other through decisional balance framework one at a time 10 minutes each Pick an action or topic that you are ambivalent about working on: Importance = 4, 5 or 6 to start with There is no need to write anything down – use a conversational approach: Clarify beginning level of importance Use the quadrants approach or use the key questions on the next slide Finish by asking if the things you have discussed have helped your partner to make a decision to take action or not on their issue, or Ask whether the benefits or consequences to themselves or others are important enough for them to want to work on this issue further Clarify RICk to see if any of it changed P: To practice the technique This slide is animated T: You are now going to work through decisional balance in pairs You have a choice of three tools that can prompt you in relation to the questions to ask: You can look at the decisional balance conceptual framework prompt sheet (Appendix B, page 63 in your workbooks) You can use the key questions in your handouts We will leave the key questions up on the next slide once you have had the chance to read this slide. Give the participants some examples as to what they might be ambivalent about: Should I go for that promotion, join the local yoga class, have the second glass of wine tonight, change house or spouse, get rid of the kids, do the dishes after dinner or in the morning, buy a new car, go to Bali or Fiji for the family holiday? (G Appendix B p.63 & Appendix C p.65)

Decisional balance key questions
What are the benefits of what you are currently doing? What’s the downside of what you are currently doing? What are the possible long-term consequences for you and the things/people that are important to you? * Why might you consider doing things differently? What benefits could you expect from this? * What’s the downside of doing things differently? Is anything that you have mentioned important enough to make you want to work on this issue? * Questions that may increase Importance T: These are the key questions that you can use to prompt you through decisional balance. For more assistance, see the relevant pages of your manuals (G Appendix B p.63 & Appendix C p.64)

How did you go? Who decided to make a change and who didn’t?
Who would you use this technique for? P: To debrief the exercise T: What would you like to say about that exercise? Workshop the questions on the slide. Make the point that as a clinician you might have felt really uncomfortable or clunky with that exercise, but as clients, many of you found the exercise really useful. Ask participants: Do you need to do the whole of decisional balance for this to have an affect? E.g. if importance is low, you could ask what are the long-term consequences of current behaviours / benefits of making changes. It doesn’t have to be done as a whole in one consultation, but the questions can be used as various points to get the client thinking about the consequences and/or benefits. Prompt participants to complete the decisional balance question in their PP and ET self-appraisal form. Optional to use in the debrief: When I hear myself speak, I learn what I believe.

Possible outcomes from decisional balance
Client decides not to work on chosen category Client decides to take action within the category Client needs more information to make the decision Client remains ambivalent P: To highlight the potential outcomes from providing DB assistance This slide is animated T: There are four possible outcomes of decisional balance. The client may decide it is in their own interest, or they may decide that it is not. E.g. Farmer from KV, who’s at risk of diabetes. He turns up to appointments with his pack of Horizon’s in his top pocket, almost as though to say “you can make me change”. He’s been marched down to dialysis, but he’s told his clinician’s my father died at 63 years, I’m 62, I’m living on borrowed time. Drug and Alcohol clinician: Clinician worked with a drug-user in his early 20s, it’s fun, I enjoy it, I’m not going to change. She said, that’s fine, it’s your choice, but please ring me when it’s not such fun anymore. Two years later, out of the blue, she got a call – “hi it’s me, it’s not such fun anymore”. The client may realise that they need more information before they can make a decision. You may not be able to help them with the missing information. They may need to go away and find it. Or they may remain ambivalent. In all cases, you have fulfilled your duty of care if the client is fully-informed about the issue and has been helped to explore the issues and how they will impact on them and the things that are important to them. The may need time to process this information after leaving your consultation, before they can make a decision. Emphasise the point that we cannot change our clients. We can’t give them responsibility; they have to take it. If you are frequently finding that clients are deciding not to change, you may want to brush up on your MI & Decisional balance skills. Ask: what do you do if your client decides not to work on an issue as a result of decisional balance? (return to agenda setting and/or have an open door policy re: returning in the future) What if the client’s importance is already high and they are ready to work on making changes? [you can still check that the client knows what benefits they expect to achieve if they do take action] Outro: Now we’ve hopefully got our client below the line, I’ll hand over to X to introduce an essential technique below the line. ET - e DB Examples

Common below the line barriers Thinking & emotions
Undermining beliefs: Treatments shouldn’t have side effects, If it hurts, I can’t do it, It’s not fair!, I feel okay so I must be fine Uncertainty: I am not sure whose advice I should take Unpleasantness of new things: It will hurt, It is too much effort Procrastination: I’ll do it later Energy levels: It’s all too hard, I am too tired Fear/concerns about injury: Exercise may aggravate my condition, I can’t exercise I have arthritis P: To highlight how everyday thinking patterns can frequently get in the way of our being successful at taking action. We need to anticipate this in our clients This slide is animated T: We have discussed that there are BEST barriers both above and below the line. Below the line when people are striving to make changes, many barriers reside in our heads. Link this discussion about barriers with the BEST discussion earlier in the day, and explain that we will now be looking at the ‘E & T’ in BEST. Mention up to 3 points from the slide and let the participants read the rest. Undermining Beliefs: Are these statements are familiar to you? (circle undermining beliefs with pointer) Beliefs and expectations re disease/condition and treatment options are often unrealistic. Procrastination: Thoughts don’t even have to sound negative, they can be more neutral like “I’ll do it tomorrow”. Fears and concerns about injury: An example of this was a physiotherapist doing strength training with worker’s compensation clients who had back injuries. How do you think they reacted to lifting weights? Fearful of causing more injury. He decided to use Bean bags instead of hand weights. How do you think his clients reacted: “hey, this is fun!” Same weight, but a change in perception. The full information for all points is below. Only mention around 3 points, but the ones you mention may change depending on the type or interest areas of the group. Additional optional notes: Competing beliefs: Research says if someone believes you only because you are perceived to be an expert, their belief in your information will only hold until the next perceived expert comes along. E.g. My next door neighbour's vet’s mechanic said the Atkins diet is the way to go. Unpleasantness of new things: If you don’t tell someone about two day delay muscle soreness after taking up exercise, they may give up and say “I knew this will be painful, what’s the point, its getting worse” .

Addressing everyday thinking barriers
Thoughts Health Behaviour Feelings P: To introduce the concept that what we think (say to ourselves/self-talk) effects what we do. We need to identify and address thinking barriers in our clients so they can be more successful in their change attempts T: Do you think your clients are aware that their thinking may be undermining their attempts to be healthier? Even if people are aware of their thinking patterns, they don’t always know or believe that they can do something about this. It is our role to help clients identify and address thinking barriers The technique we are going to use comes from Cognitive Behavioural Therapy or CBT. Who uses CBT techniques? For those less familiar with CBT the basic tenet of this theory is that how we interpret a situations affects our emotional & behavioural responses to that situation. In other words, what you say to yourself impacts on how you feel and what you do. By intervening and changing thought patterns, we can change behaviour and support the creation of new habits. But this does not mean that we are getting into therapy and digging down to a schema or core belief level. You don’t want to do that unless it is your role to provide counselling or therapy. The aim in the health change context is to only examine thoughts that directly interfere with specific health-related behaviours. We are dealing only with specific surface level thoughts that are impacting specific health behaviours. Use early riser example (see p. 58 in the guide). Ask who in the room has ever intended to get up and exercise in the morning, but chosen to sleep in instead. Then highlight the specific thoughts they engage in that leads to doing or not doing the exercise. You can use the ‘early riser’ example with your clients to help them to understand this concept. It is in page 58 of your workbook and you can follow this guideline. (from: Aaron T. Beck’s cognitive therapy )

Turning ANNTs into PETs
Automatic Neutral or Negative Thoughts Positive or Enabling Thoughts P: To provide a structure for changing thoughts that is consumer-friendly and easy to relate to T: This next technique presents a method to help clients change the sort of thinking patterns that are unhelpful for behaviour change, i.e., ANNTs, into that which supports the intended action, i.e., PETs. We call this ANNTs to PETs so that you don’t have to use complex psychological jargon with your clients. The aim of the technique is to change or replace negative or neutral undermining thoughts with positive or enabling thoughts by using a concept that clients can easily understand: turning ANNTs into PETs. ANNTs can be described as prickly, creepy, crawly annoying things that undermine intentions. PETs can be thought of as friendly, helpful or comforting things that spur you to action. In other words, ANNTs are unhelpful thoughts and PETs are helpful thoughts. Techniques for turning ANNTs into PETs can be used whenever unhelpful thinking patterns might get in the way of a client committing to or carrying out their intentions. The main use of these techniques in the HCA approach is below the decision line during action planning. (Adapted from Grant & Greene 2001) (G53)

More about ANNTs Fire ANNTs I can’t do this. This is hopeless, why bother! Sugar ANNTs I’m fit as a fiddle. I don’t feel sick, so I must be OK! Angry ANNTs (Resist ANNTs) No one tells me what to do! Garden Variety ANNTs More sleep would be good… I’ll just have this cup of coffee… P: To introduce the notion that not all ANNTs are negative and not all PETs are positive. Different people relate to different types of ANNTs and PETs. This slide is animated T: One thing to keep in mind when looking for ANNTs or unhelpful thoughts is that different clients may relate to different varieties of ANNTs (and different varieties of PETs) Some ANNTs are quite negative, we call them ‘fire ANNTs’, the ones with the real sting in their tail. Sugar ANNTs are more unrealistically optimistic thoughts e.g., ‘I’m as fit as a fiddle’ Then there are Angry ANNTs, which have a tone of resistance or defiance. Or, more neutral thoughts, called ‘garden variety ANNTs’ e.g., ‘more sleep would be good’. This is a bit of gender bias, but which type of ANNTs do you think that women engage more in? (Fire ANNTs) What about men? (Sugar ANNTs, or Resist AANTs) But we all engage in garden variety ANNTs. Just like the ANNTs, different people relate to different types of PETs. Not all Positive or Enabling Thoughts (PETs) are warm and fuzzy. While some people might need nurturing or comforting PETs, other people relate more to PETs that give them a little kick to spur them to action. (G53)

Turning ANNTs into PETs: Early Riser example
Decision point & decision being made Automatic neutral or negative thoughts (ANNTs) Negative consequences of ANNTs & not taking intended actions Positive or enabling thoughts (PETs) Situation: The alarm goes off at 6 am Decision: Will I or won’t I get out of bed & exercise before work today? I’ll do it tomorrow Just one more press of the snooze button… It’s cold out there It’s nice and warm in here I’m tired and need more sleep I deserve to sleep in Confidence in getting up - 2/10 I don’t get up I feel more tired I feel like I’ve let myself down I get grumpy with myself (and others?) I never achieve my fitness goals I beat up on myself & feel like a failure I will feel more energised if I get up now and do it I’ll enjoy it once I get going My mood will be better I will achieve my fitness goals I’ll feel good about myself Just do it! Confidence in getting up - 9/10 P: To introduce the underlying rationale behind turning ANNTs into PETs and to introduce the formal method. T: Let’s look at an example to help understand how this technique works before we do another pairs exercise. We talked your through this Early Riser example before. Here is a generic version of the example with common responses filled in. See G52 for the questions that a clinician might ask in relation to this example. The Early Riser example can be used to help clients understand the concept that what they say to themselves can affect whether or not they do what they had planned to do. Keep in mind that you may never need to use this formal method of turning ANNTs into PETs, but it will help you to know what you are trying to achieve by using the short conversational method that we will cover later. Outro: I’ll hand you over to x to take you through a practical exercise (G59) 98

Turning ANNTs into PETs Short method: Thinking strategies to support action plans
Do you ever procrastinate or talk yourself out of doing things you had planned to do? What excuses do you usually give yourself for not taking action? What do you need to say to motivate yourself instead, to make sure you do what you are planning to do? How will you practise these thoughts so that you can say them to yourself when you need them? P: To highlight the common occurrence of every day thinking barriers and to present the informal short method of identifying and addressing thinking barriers This slide is animated T: We previously discussed thinking barriers and worked through a formal method to address them. Here is a quicker, more simple way to do this. How many of your clients are procrastinators? If so, then this set of questions can help you to help them to actually do what they say they are going to. Simply ask your clients: Do you ever find you talk yourself out of things you planed to do? If the answer is yes, then you can ask the questions on the slide (and in the Guide) If you ask a person “what else do you think might get in the way?”, sometimes they will answer “me!”. That flags that they are likely to have thinking barriers when they go to do what they planned to do. (G54)

Video – Terry Identifying and addressing thinking barriers Video - Terry Thinking and Planning: 4 mins 45 sec P: To demonstrate informally using cognitive change strategies in a consultation to identify and address thinking barriers T: We’ve seen Terry before in the above the line phase of a consultation. Now this video shows you how thinking barriers can be identified and overcome in a very conversational way. Debrief points: Exploring and normalising thinking The client first principle: who was coming up with the PETs? Not the interviewer Make the point that Terry’s strategies and PETs would not be expected to work for everyone. But they work for him because he came up with them on that basis. Prompt participants to complete the decisional balance question in their PP and ET self-appraisal form. Outro: I’ll hand over to X to the final essential technique ET - f Terry below the line video 104

Tracking actions versus outcomes
Why do we monitor physiological outcomes? What’s the problem with only monitoring physiological outcomes? What are the benefits of tracking actions also? P: To highlight the importance of tracking and different methods of tracking This slide is animated T: Our final technique is crucial to helping clients stay on track. As clinicians we are used to monitoring patient outcome measures Are these the only things that we should track over time? Workshop: Ask the questions on the slide Reasons for tracking actions/behaviours in addition to monitoring outcome measures. helps people to persevere when the outcome measures can be expected to take a long time to move so that people can look back to see how far they have come over time, to maintain motivation, to see that they are having some successes… if you track clinical outcome measures in isolation from behavioural process goals it may set clients up for failure i.e., they will only focus on the outcome goal and if they don’t get the outcome they expect, they may give up. If we use BGLs as an example, other than diet and exercise, what factors affect BGLs? (illness, infection, medication, stress, depression). These things are not fully under our control. So although we need to measure outcomes, we want the client to focus on the behavioural process goals – because we can control what we do, but not necessarily the outcomes we get. So the message is to monitor outcomes and track behaviours. (G60) 105

Tracking and monitoring strategies
Pen & paper Electronic Other visual or graphical Accumulating objects Recording measurements Reward systems Subjective scales Others? P: To highlight the importance of tracking and different methods of tracking This slide is animated T: What sorts of tracking methods are you using already? Workshop: What tracking or monitoring methods do you use to show clients they are succeeding? (Keep only the title up while they make suggestions) If clients do the specific things you recommend them to do for their condition/issue, what benefits would they notice? (i.e. if a client with leg wounds elevates their legs and uses compression stockings, they will have less swelling. So tracking methods could be tracking size of the wound, circumference of the calf, ability to put on favorite shoes, ability to stand for longer periods without pain etc.) Try to get participants to think of specific tracking methods that fit with the issues they work with. 3. (Then flick up the dot points and cover any that were not suggested) Additional example (being creative with rewards systems): There was a nursing home that wanted to increase the incidental activity of the residents and they created a whole game based on ‘race-around-the-world’ so residents had pedometers and they monitored distance walked and mapped it to different countries. When they reached a country they would all celebrate by eating the traditional food from that country. (G61) 106

What you track is what you get
Family blocks of chocolate Week Starting (date) Mon Tue Wed Thur Fri Sat Sun Total days goals met Ex hours total 28/4 Chocolate 3 squares 2 squares 3! Exercise 15 mins 20 mins 10 mins 45 mins! 5/5 12/5 P: To encourage clinicians to encourage clients to track successes rather than failures and to use food and other diaries in a positive rather than punitive way (track actions that maintain motivation) This slide is animated T: If what you track is what you get, we want to track the things we want to achieve, not the things we want to avoid. This is a method that you can use to help clients to track their actions in a way that is likely to motivate rather than demotivate them. (If what you track is what you get, then we want to focus clients on the things they want more of, not the things they are trying to avoid. Clinical examples of use of habit change diary.) You don’t have to use this particular tool, you can create your own, but if you want to you can download it from the HCA website. It is called a habit change diary. The idea is that you write in the behaviours you want to achieve and record the days you achieve them. (Refer to list on whiteboard to relate to participant’s examples, e.g. days compression stockings worn or fluid restriction goal met) For example, this client had a chocolate minimisation of goal of eating no more than 4 squares of chocolate everyday. She achieved this three times during the week. But on the other days, she ate a whole family block of Cadbury’s chocolate per day. (Use animation to show red arrows). What would she have focused on if she had written in the family block of chocolate eaten on Monday? What would have happened as a result? This client also had pain issues so her goal was to do some exercise during the week, regardless of how much. Previously she thought that if you don’t do 30 minutes, there is no point doing any exercise, so she did none. According to the ‘one step….’ principle she was now attempting to do small amounts of exercise regularly to see if she could build up to 30 minutes in a day slowly over time. Describe how food and exercise diaries can be reframed to be motivating rather than de- motivating: highlight the things the client did right, rather than ‘wrong’. Add other client examples as desired, e.g. bulimia. OT used this diary with a patient with bulimia to monitor and focus on binge free days. In the first week she managed only one tick for one day. However once she had achieved that, what do you think she focused on? (getting more ticks!). In 2 months she was purge-free except for one day when she had had a fight with her boyfriend. Prompt participants to complete the tracking and monitoring question in their PP and ET self- appraisal form. ET - g

Which technique would you use…?
P: To wrap up section and test understanding. T: Let’s recap the techniques we have just introduced. Which techniques help you to determine where the client is in the behaviour change pathway? Why have we separated out RICk radar and Ask RICk? Which techniques would you use for every single client? Which techniques would you use only some of the time? When do we use… discuss the use of various techniques Stick the ET white card on the top RHS of the generic behaviour pathway.

Setting the scene for health change
Section 4: Setting the scene for health change T: So far we have talked about the overall HCA approach, gone through the practice principles in detail and reviewed the essential techniques and when you might use them. Setting the scene is Setting the scene is all about setting up accurate expectations For the rest of the workshop we are going to talk about how to bring together the principles, techniques and framework into a systematic approach to providing behaviour change support. start of this. If you set the scene adequately for your consultations, you will create a comfortable environment for your clients and set up accurate expectations of your role and theirs in managing their health. (G inside Section 4 tab)

What are you offering clients?
A complimentary health risk assessment and information More energy A better ability to do the things that are important to you in life Functionality Physical and emotional resilience (coping)

What can you ask clients?
This program helps people to have better general health so that they can avoid developing chronic diseases such as diabetes and heart disease in the long term. In the short term it can help you to feel better, have more energy and a better ability to do the things that are important to you in life on a daily basis. Is this something that interests you?

What I am not going to do Tell you all the things that you already know Tell you to go on a diet Tell you to engage in a difficult exercise program Tell you to make sudden big changes to your lifestyle Add pressure to your life (in fact I can help you to do the opposite)

What I can do for you Provide a health assessment that will tell you what risks you might have for developing chronic diseases like diabetes or heart disease. Provide any extra information that you might need to help you to be healthier. Help you to change things a bit at a time so that the changes stick. Ensure that any changes that you make are suited to your particular lifestyle. Help you to do things in a manageable and sustainable way that is as stress-free as possible. We start with where you are at now, and slowly chip away at changing any unhelpful habits to be more healthy and give you more energy.

Section 5: Above the line processes
T: We are now moving on to Section 5 in your manuals – the above the line processes

HCA 10 step decision framework Above the line processes
Set the Scene & Explain Your Role  Identify Clinical Issues & Broad Lifestyle & Treatment Categories  Prioritise & Choose a Category to Work on  Ask RICk   Make a Decision Decision Line Ready to Take Action P: To introduce and provide an overview of the above the line processes and to assure participants that this is a flexible and useful decision framework, not a concrete set of techniques. T: Let us look at the above the line processes. As you can see we are working on increasing readiness by providing knowledge in a client-centred way and aiming to build motivation in order to encourage the client to commit to taking action to improve their health or quality of life. Remember that the steps in this framework are simply prompts for you to consider if particular barriers might cause your clients to be stuck somewhere in their behaviour change pathway and prevent them from committing to act on health advice. You may be addressing some or all of these points already in your consultations. If not, you might consider if it would be worth incorporating an extra step or two for your clients. Workshop: What processes do you already do? Make the connection between assessment and macro-level education and step 1 Readiness Build Motivation RICk = readiness, importance, confidence, knowledge (G inside Section 5 tab)

Key questions above the decision line
Does the client know and understand the broad lifestyle & treatment categories applicable to their condition/s? Have they been assisted to collaboratively prioritise these? Are they ready, willing, able and committed to taking action? Decision Line Ready to Take Action P: To provide another (simpler) way of thinking about the above the line steps. T: In essence, the above the line processes help you to answer these questions about your clients. Above the decision line the main barriers that stop people from taking action are motivational How do these processes relate to the generic behaviour change pathway? Note: this diagram is on the reverse side of the section divider tab Build Motivation (G inside back cover)

Step 1: identify clinical issues & broad lifestyle & treatment categories
Assessment, referral letters, care plans, client information Check client knowledge and understanding of condition/s: Health conditions, clinical indicators, risk factors Implications of these and reasons for clinical targets Check what they already know before offering information Provide treatment advice, education & guidance: Broad lifestyle and treatment categories for action Rationale for taking action (macro level education) Check what they are already doing before offering advice P: To discuss the purpose and nature of Step 1 This slide is animated T: Working through Step 1 is a collaborative process where clinicians need to blend their clinical expertise with a client-centred approach. Step 1 involves establishing what a client’s health issues are and the broad lifestyle and treatment categories of action that the client can take to address these issues over time. Identification of a client’s health issues may occur through formal or informal assessment, review of a patient care plan, referral letter or clinical notes from another clinician and/or from asking the client about their health priorities. If part of your role is to conduct an assessment, you would do this prior to or as part of Step 1. The treatment and lifestyle categories that are addressed in a consultation will be different if you are in an overall case coordination role compared with a profession-specific consultation or a disease-specific program. In a case management role you might deal with ALL of the relevant categories for the multiple conditions that a patient has. In a profession-specific consultation (e.g. dietetics, physiotherapy, diabetes education, podiatry etc.) the treatment and lifestyle categories relevant to your consultation might be narrower in range. The outcome of this step should be that each client knows and understands four sets of information: what their health conditions, medical indicators and lifestyle risk factors are, as well as any clinical targets related to the client’s measures the reasons why these conditions and risk factors might be a problem for the client (including the short- and long-term consequences), and the relevance of the client’s clinical targets the full range of general categories of lifestyle and treatment activities that the client could action to manage their health over time (to meet or move towards any clinical targets) the reasons why taking such action should have a positive effect on the client’s health outcomes and/or quality of life. Why would you First ask, then offer information when someone has come to you for advice? [find out what the patient already knows and what they are already doing so that you respect their current knowledge and actions, have the opportunity to correct misinformation, avoid having the patient ‘switch off’ by being told what they already know etc. ] What are the possible barriers or sticking points for clients at this step in a consultation? Invite participants to write in their own words in the Guide sections. (G93)

Step 2: prioritise and choose a category to work on
Prioritise broad lifestyle and treatment categories Balance duty of care with client choice Prevent the client from becoming overwhelmed P: To discuss the purpose and nature of Step 2 and emphasise the need to balance duty of care with client choice. T: The outcome of step 1 can be a long list of things that a client needs to do to get better health outcomes. This can lead to what we call ‘messy head syndrome’. Workshopping: What do we mean by collaboratively prioritising with the patient? What’s the difference between telling someone what the priorities should be and asking the client what the priorities for their health are. Why would Step 2 be important? What is the purpose of it? What happens if you don’t do Step 2. What does it mean to balance duty of care with client choice? Step 2 is necessary to help clients to prioritise the order in which they tackle the various lifestyle and treatment categories over time, and to choose one or two categories to start with. This step requires clinicians to balance their duty of care to inform clients about clinical priorities with each client’s right to choose whether or not to take certain actions in their life. If particular actions are more medically critical to take than others, it is a clinician’s responsibility to ensure that their client understands that this is the case. This is not a non-directive approach where you simply ask the patient what they want to do. highlight that many health professionals are already doing this and not realising it. Others will be more aware of actively helping clients to prioritise their actions. A copy of the messy head syndrome cartoon is available for download from the HCA website (free) and can be used to show clients. Invite participants to write in their own words in the Guide section for Step 2. Additional notes on Steps 1 and 2: Gives you a consideration set to come back to - if they are not ready initially choose, or as a continuing issue to work on later. Lays out all possible things they can do, gives them hope, engender pathways thinking, trial and error. Outlining categories is necessary when clients have multiple health behaviour changes that they could work on. It is a form of problem-solving that addresses “messy head syndrome”. It organises and prioritises options for HBC, because patients are often expected to work on too many issues in the context of CCSM. It helps to minimise the client’s resistance to engaging in dialogue about change. (G99)

Step 3: ask RICk  Readiness, Importance, Confidence, knowledge
Use your RICk radar, but when in doubt, ask the client P: To discuss the purpose and nature of Step 3 This slide is animated T: Step 3 relates to using your RICk radar or asking RICk What is the point of asking RICk here? [It helps you to identify whether the client is above or below the decision and, therefore, what to do to support the client’s health change.] The RICk principle suggests that clinicians should always be on the lookout for signs of low readiness, importance or confidence while also being aware of their client’s knowledge of a particular health area. Steps 1 and 2 identify health areas that clients can work on. Step 3 is a prompt to remind clinicians to actively consider a client’s RICk levels for a lifestyle or treatment category, before engaging in discussion about what the client needs to do to take action in this category (i.e. goal setting and action planning). You want your clients to want to do it (above the decision line) and to be able to do (below the decision line)  link this back the HCA generic behaviour change pathway (G105, 38, 42)

Client choices: Clinician choices: Step 4: make a decision “yes” “no”
“maybe” Clinician choices: Client “yes” - proceed below the decision line Client “no” – revisit Step 2 or invite them to opt out Client ambivalence – ask decisional balance questions P: To discuss the purpose and nature of Step 4 This slide is animated T: In Step 4 the clinician makes a decision about what action to take in response to a client’s RICk profile and/or the client’s decision about whether or not to work on the prioritised treatment or lifestyle category. There are three possible pathways at Step 4: A definite “yes”: The client has clearly stated the general goal is important to them and is ready to work on it. Proceed below the line to step 5. A clear “no: The client doesn’t think it is important and/or isn’t ready to work on the issue – revisit step 2. However, you could at least ensure that the client understands the consequences of not taking action. Would anyone feel uncomfortable if a client chose not to work on an issue you thought was critical? The solution is to double check that they understand the consequences of NOT taking action and the benefits of taking action. What part of RICk is this confirming? [k] The client is ambivalent (i.e. in 2 minds). They may be saying I “should” do this but there are lots of reasons stopping them taking action. If you were using numbers, their importance would be 4-6/10 or ‘50/50’. This is where you would use decisional balance questions. (G109)

Video – Greg Steps 2-4 Video - Greg Steps 2-4 – 8 minutes P: Shows how you might put steps 2-4 together in a smooth coherent conversation. T: We are now going to watch a video that puts together Steps 2-4 in a consultation. This video starts at the end of step 1 (doesn’t show the assessment that was conducted). Mention that Greg was seen in a ‘what not to do’ clip, but that this is the REAL interview (recorded before they were asked to do the fake one which deliberately showed the clinician jumping in) We will write on the board what is happening and in the format of the Personal Self-Management Plan Whiteboard: Draw Personal Self-Management Plan framework Write in client issues (step 1/column 1) Prioritise (Step 2/column 2) RICk (Step 3/RICk columns) Debrief: What would you like to say about the video? Working through the steps doesn’t have to take a long time. The previous video of Terry also showed steps 1-4 in a 4 and a half minute conversation. This one was 8 minutes. Did anyone notice that the client asked the clinician what she thinks he should do? What would have happened if she’d just given him education/advice? The clinician investigated motivation and importance by asking about personal benefits. Greg steps 2-4 video

Step 1: using assessment data to inform behaviour change
Patient problems, needs & relevant conditions Clinical goals Required treatment & services Provider for treatment & services Type 2 Diabetes HbAlc < 7% 3 monthly checks Diabetes Education Exercise Program Foot care GP/Practice Nurse D. Educator/Dietitian Ex. Physiologist Podiatrist Hypercholesterolaemia TC: < 4mmol/L LDL < 2.5mmol/L HDL> 1.0mmol/L TG < 2.0 mmol/L Lipitor 10mg Low saturated fat diet Dietitian Obesity BMI < 25 Maintain a healthy diet Back pain Reduce pain & improve mobility Physiotherapy Bone density scan Physiotherapist Nuclear imaging P : Showing how to work with a care plan while helping them embed client-centered practice. T: Takes to form of your assessment  treatment categories, but the way to do that is….A Care plan can is often used to identify or document clinical issues (step 1) Workshop: Who receives or creates care plans? What are the advantages of using a care plan? [structured; identifies issues; good example of most of Step 1] What are the potential problems with care plans? [overwhelming; clinical; not personal; not motivating; doesn’t tell person what they need to DO] What will a client do with this? [not much] How can you make discussion of a care plan client-centered, in a way that facilitates the client’s behaviour change process?

Lifestyle/Treatment Categories
Steps 1-4: Case coordination example Documenting priorities to create a personal self-management plan Lifestyle/Treatment Categories Priority Readiness Importance Confidence Knowledge Date 1. Medications (see GP) 2 Moderate 2. Rehabilitation exercises (already provided) 3. Wound care 1 High Low Good ##/## 4. Dietary changes (see dietitian) 3 5. Tests (bone density scan & bloods) 4  6. Home assessment (see OT) X P: To introduce the HCA Personal Self-management Plan (PSMP) as a key piece of documentation to help clinicians to move from medical focus to behaviour change/self-management focus in a consultation T: Many organisations are using this table in conjunction with care plans to document patient priorities and choice This is HCA’s key document that can help you to facilitate collaborative prioritisation of health issues with the client, while exploring their motivation. You may discuss multiple issues in one consultation. However, after outlining the treatment and lifestyle categories, you would work through these one at a time with the client. This is the one document that HCA recommends programs and services integrate into their paperwork or electronic systems. After documenting assessment and treatment details, this table helps clinicians and clients to shift their focus to what the client can do over time to get better outcomes. It is a critical document to quickly and efficiently record the L&T categories discussed with the client and to work through Steps 1-3. This document can also enable the sharing of information with other members of a multi-disciplinary team so that they know what has already been discussed with the client. Care plans and treatment plans document assessment and identification of clinical issues (the first part of Step 1). Column 1 in this table documents the second part of Step 1 (identification of treatment and lifestyle categories). Column 2 documents step 2 (prioritisation of categories and choice of category to start with). The next four columns document Step 3 (exploring RICk) Annex H in your manuals shows a downloadable form that you can use if you wish. It also contains date and comments columns and tips for filling in the form. The example on the slide shows how it might be filled in during a case coordination consultation. However, if used for profession-specific or condition-specific consultations it would look a bit different because it would show different categories in the first column. The next slide gives an example of this. (G115, Appendix I p.121)

Lifestyle/Treatment Categories
Steps 1-4: profession-specific example – managing arthritis Documenting priorities to create a personal self-management plan Lifestyle/Treatment Categories Priority Readiness Importance Confidence Knowledge Date 1. Medications - Taking action  ##/## 2. Specific exercises 1 Moderate High Low Good after educ 3. General activity 2 4. Pain management strategies Pacing activity 5. Weight management X X P: To provide an alternative example of filling out the PSMP T: Here is an example of a personal self-management plan for a patient with arthritis. It could have been completed in a physiotherapy or exercise physiology consultation for example. Explain use of the document. Suggestion: Hyperlink other condition or profession-specific examples as required. Outro: I’ll hand over to X for the practical exercise. (G115, Appendix I p.121)

Summarising above the line processes
Lifestyle/TreatmentCategories Priority Importance Confidence Readiness Knowledge Date 1. Eat healthily 2 2. Be more active 3 3. Reduce my alcohol consumption 1 6 Pretty low So-so  ## 4. Manage my stress 5. Reduce smoking 4 6. Get more sleep P: To practise Steps 1-3 and to practise using the HCA personal self-management plan (PSMP) T: Now you will have the opportunity to practise steps 1-3. In your case, it will focus on self-management for wellness and/or chronic condition management, depending on your own personal health issues. Walk through column 1 (issue identification- outcome of step 1), 2 (prioritization & and choosing) and the next 4 (exploring RICk) to explain what to do. Any questions or clarification? Highlight that this table can be filled out in a flexible way. You can use whatever values for RICk that you feel comfortable with and that suit your client. Ask participants to try out different ways of asking RICk that don’t use numbers Prompt participants to read the relevant section in the Guide that describes how to use the PSMP. HMS Screenshots

Identify clinical issues / lifestyle / treatment categories
Prioritise & choose one category to work on Ask RICk for the chosen category Use the decisional balance technique if readiness or importance are low to moderate T: This is a summary of the instructions for this exercise. Demo: Facilitators to demonstrate this to the participants (Facs only, do not invite a participant to complete this). Be aware there is an explanation about how to fill out this form in you workbook and a copy of the form in Appendix I) Does anyone have any questions, or would you like to clarify any points before we start? I will put the previous slide back up in a minute to provide you with some prompt questions. Remember that you will only ask RICk for one category: the chosen one. Re-emphasise that Step 1 is identifying the issues; Step 2 – prioritizing issues and choosing an issue to work on; Step 3 asking RICk. Can be flexible in how you document this You have 5 minutes each before you swap roles; raise your hands if you have any problems/queries. Note: Give the participants 5 minutes each. They may need a little longer than this for the first partner while they settle into the exercise. (G115 & Appendix I p.121)

Section 6: Below the line processes
T: We will now move on to the next section of the manual look at the below the line processes

HCA 10 step decision framework Below the line processes
Ready to Take Action  Generate Personal Goal Options  Choose & Refine an Option  Create an Action Plan  Identify & Address Barriers  Ask RICk  Consider Review & Referral P: To introduce and provide an overview of the below the line processes. T: Prior to crossing the decision line the client will have indicated that they are ready and willing to engage in planning how to take action in a particular lifestyle or treatment category. The nominated category remains the focus as clinician and client work through Steps 5-10 to identify and formulate appropriate personal goal/s and action plan/s. The below the line steps should all occur as one fluid process. Each step ensures that particular barriers are identified and addressed as necessary, and that the client has sufficient confidence to be able to carry out their agreed actions. Workshop: What processes do you already do? Readiness Build Confidence RICk = readiness, importance, confidence, knowledge (G inside Section 6 tab)

Key questions below the decision line
Ready to Take Action What options do they have for taking action in a particular category? What is their personal goal and plan? Are they confident they can do this and what might get in the way ? Will I review the client and what other support do they need? T: The below the line processes help you to answer these questions about your clients. Below the decision line the main barriers that stop people from taking action relate to confidence (self-efficacy) How do these questions relate to the generic behaviour change pathway? Note: this diagram is on the reverse side of the section divider tab Build Confidence (G inside back cover)

Step 5: generate personal goal options
Lifestyle/treatment category Personal goal & action plan Options Ways to generate options Treatment strategies from assessment Collaborative problem solving using: Client first technique Menu of options technique P: To discuss the purpose and nature of Step 5 T: The aim of Step 5 is to collaboratively generate a number of different options or alternative pathways for the client to take action in the chosen category. It would be easy to jump ahead and set a goal and develop an action plan as soon as the client has confirmed that they are ready. Why might it be useful to identify some alternative options prior to picking one to refine into a personal goal? [provide back-up options, promote choice and personal control, education opportunity] Some clients will be able to think of a number of options themselves. Other clients will need a significant amount of help from their clinician to generate clinically appropriate alternatives. For example, to help a client to take their medications more effectively, a clinician and client might consider the following options: speak with the pharmacist about Webster packs and/or a home visit; make an appointment with their GP to review specific medications; speak with their asthma educator about their medication administration; use a calendar or tick chart to log their tablet taking; or set a series of alarms on their mobile phone to remind them when to do particular things. Just because the client is ready, doesn’t mean that we jump back into ‘advice giving’ mode. Remember, to ask first, then offer (use the client first and menu of options techniques. Invite participants to write in their own words in the Guide section for Step 5. (G125)

Create goal hierarchies for education, menus of options & consistency of advice in programs
Reduce diabetes risk Increase CV exercise Water-based exercise Walk, jog or ride Group-based exercise Other... Increase muscle mass Gym exercises Home exercises Incidental activities Reduce total fat/& saturated fat Change to low fat dairy Change cooking oils Select leaner meat serves Increase fibre 5 serves vegetables 2 serves fruit Hi-fibre breads, pasta and rice Reduce body weight by 5% Reduce portion sizes Reduce serves at dinner Manage night time eating P: To introduce the concept of goal hierarchies to guide the provision of menus of options in clinical practice and to organise and standardise advice provided in programs and group education sessions. T: If you run programs, consider writing up a goal hierarchy to ensure consistent education messages and expectations The health issue or clinical focus is at the top of the goal hierarchy, in this case reducing risk of diabetes. Step 1 would include checking for and weaving in knowledge about diabetes risk as a health issue, as well as providing the broad education on the general categories that relate to this clinical issue. Then in Step 2 you might be making recommendations and helping the client to prioritise which category they address first. Underneath these categories, there are specific options. This accords to Step 5, and could be generated through conversation with the patient (using client first and menu of options techniques), from a created goal hierarchy (i.e., those on the HCA website or create your own for your programs), or developed through group participation from feedback from group participants. This is an example of how a goal hierarchy can be used in a program e.g., ‘Live Life Well’ diabetes prevention program. Research suggests that if clients achieve 4 out of 5 of these goals, their risk of developing type 2 diabetes is be reduced by almost 60% ‘Live Life Well’ found that people were working on dietary changes but avoiding strength based training. Can also be used for data collection/aggregation system to group data when individuals are pursuing different goals. Many such menus of options are available in the HCA Resource Library. Another example is at Appendix J, page 151 in the Guide. (G Appendix J p.151)

Step 6: choose & refine an option
Help the client to choose a personal goal option and state it as a personal goal in one or two sentences: What How much How often When to start When to complete or review P: To discuss the purpose and nature of Step 6 T: Step 6 simply involves choosing one of the options and stating exactly what the client intends to do in the form of one to two sentences. This becomes their personal goal. The main thing is to ensure that you ask the client relevant questions so that their goal has the required level of detail in it. See the relevant section of the Guide for examples for personal goals. Invite participants to write in their own words in the Guide section for Step 6. Note: If SMART goals are mentioned, advise that personal goals are formulated to be SMART (specific, measurable, attractive benefits, realistic, time-framed). However, HCA has moved away from using the acronym because many practitioners, organisations and clients get confused about how to frame a SMART goal and focus on the acronym at the expense refining a workable personal goal. Another pitfall with using the SMART acronym is that many people set SMART goals around clinical outcome measures – these are not fully under the control of clients, tend to move slowly, and don’t tell the client what actions to take to achieve the goal. Additional Notes: What’s the problem with saying I want you to elevate your leg, I want you to monitor your BGLs? An e.g. of a personal goal: Raise leg to hip height at least once per day so that my wound can heal and I can get back to bowls. (G131) 141

Step 7: create an action plan Include only as much detail as necessary for the client to feel confident: Actions or tasks Memory prompts Support mechanisms Thinking strategies Emotion management strategies Backup plans Tracking and monitoring strategies Review and referral details P: To discuss the purpose and nature of Step 7 This slide is animated T: Action plans don’t have to be formal documents. An action plan should outline what a client needs to do in order to achieve their stated personal goal. It should include strategies required to address any barriers that the clinician and client discuss that might get in the way of the client achieving their goal. Invite participants to read over the relevant section of the Guide for ‘How to’ questions. Remind them that they already constructed an action plan in their first pairs exercise. Ask: Does an action plan have to be written? [not if the goal and actions required are not complex, or the client is not comfortable with writing it down] The details on the slide are prompts for things to consider including in an action plan, they are not a list that must be included. Video - Beth Action plan – 1 minute (G135 & Appendix K p.153) Action plan video

Step 8: identify & address barriers
Behaviours Emotions Situations Thinking B S T E P: To discuss the purpose and nature of Step 8 This slide is animated T: Step 8 is identifying and addressing barriers to achieving a specific goal. This step occurs during action planning. Action plans are deliberately constructed around identifying and addressing behavioural, emotional, situational and thinking barriers. So keep BEST in mind. A useful way of talking about the most common barriers with clients is to divide them into planning barriers and thinking barriers. Insufficient planning and habitual thinking patterns that lead to procrastination are often the cause of inaction. Video – Cathy 4 minutes T: This video shows how a client has assimilated the trial and error approach to addressing her barriers to change As you can see in the video, this client has had a lot of thinking and emotional barriers that she is now dealing with Three years after the video was filmed Cathy was followed up. She no longer needed to see her dietitian for assistance (and hadn’t done so for quite some time) because she had learned coping and self-management skills which are helping her to stay well and to get back on track when she has a set-back. (G139) Cathy video

Common below the line barriers Behaviours & situations
Not understanding Not remembering Poor planning Strength of old habits vs. creating new ones Recurring or cyclical situations: disease episodes, depression, travel, seasons etc. Lack of support from partner/friends/family Lack of access to services Pain & disability P: To outline some common below the line barriers and to get participants to relate these to their typical client base This slide is animated T: Many of the below the line barriers can be very practical in nature. What are some of the practical barriers that you or your clients/staff have encountered? Ask the participants if they have any examples of clients who have completely misunderstood the instructions they have been given. Provide examples: e.g. using asthma inhalers incorrectly, giving the contraceptive pill to the husband (he’s the virile one); etc. Highlight the difficulty of changing habits by using the arm folding exercise, or referring to learning to drive a car. Mention selected others (recurring and cyclical situations such as depression, sharing child care, travel, seasons: do you need multiple personal goals to cater for changing situations?) See also the extended facilitators’ workshop notes for additional information. Asthma

Relapse prevention Normalise lapses and emphasise trial & error
Identify potential triggers for lapses and strategies to get back on track Change ANNTs into PETs (I have busted, I am back at the beginning again, what’s the point?) Use metaphors to stay on track (e.g. going on a journey, tortoise & hare) Average no. of relapses for people changing habits: Ave days to create habit: P: To encourage clinicians to discuss relapse triggers and trial and error in their initial consultations. This slide is animated T: Who is familiar with relapse prevention? When do you talk to clients about this? [initial session]. Thinking strategies can be critical to avoid turning lapses into a full relapse. Relapse prevention strategies should be incorporated into action plans. Does anyone use metaphors to help clients stay on track? Explain the metaphors on the slide. Average no. of relapses for people changing habits: 5 to 7 for smoking it’s up to 9. Note: European Journal of Social Psychology – 2010: Range days, average 66 to create a health habit 5 to 7 66 (range ) (EJSP 2010)

Step 9: ask RICk again RICk tip:
To check that the client’s personal goal and action plan are appropriate RICk tip: If confidence is low, adjust the personal goal and/or identify relevant barriers and add necessary steps into the action plan P: To discuss the purpose and nature of Step 9 This slide is animated T: We asked RICk above the line at Step 3, why would we check RICK again at this step? Which part of RICk is usually the most important to clarify here during goal setting and action planning? How would you phrase the confidence question? Click to show the rest of the slide text. Note that Steps 9 & 10 are a part of goal setting and action planning. Invite participants to look at the ‘How to do it’ section in the Guide (G143)

Step 10: consider review and referral
Review consultation scheduling: the lower the client’s overall confidence, the sooner the next consult should be Check RICk for attending referral appointments Track client actions and clinical indicators to review progress over time Reinforce trial and error P: To discuss the purpose and nature of Step 10 T: What kinds of things would be included in a client’s action plan as a result of step 10? What are you including in your clients’ action plans? (G145)

Conducting review consultations
Develop personal goal/s and action plan/s Give it a Go! Keep using the strategies that work and change the ones that don't Track your progress & review goals regularly Extend goals & add new categories & goals when ready Options: Continue with the same personal goal Move to a new personal goal Move on to the next lifestyle or treatment category and add personal goals for that category P: To help participants to understand the behaviour change mechanics of review consultations – keep adding personal goals/T&L categories as appropriate T: We will briefly discuss what might occur in follow up or review consultations. The function of review consultations is for people to progress through the behaviour change process. i.e. continue to address barriers to achieve a previously worked on goal, move to a new personal goal under the same category, or move to a new T & L category altogether. There is no failure in this model, you just keep tying different things until you find the things that work for you. This relates to the Trial and Error principle. Notice that you don’t just keep working on the same client goal over and over in review consultations. Invite participants to look at the relevant section in the Guide. Optional: Play Duncan video if appropriate (e.g. if high number of allied health professionals are present) Outro: I’ll hand over to X to take you through the next practical exercise (G149) (Duncan)

Practising step 5 Generate personal goal options within a category
Choose a treatment or lifestyle category from the personal self-management plan (PSMP) Generate a list of personal goal options relevant to that category 5 minutes to create a list P: The next sequence of exercises allows the participants to work through Steps 5-10 and how it applies to their clients. This slide is animated T: In a consultation, the below the line steps would be done in one flowing conversation however we will separate out the steps to help you see how the principles and techniques are used below the line. Here are the instructions for Step 5. The facilitator gives a demo of how to do this using the goal hierarchy previously written on the whiteboard Generate at least 6 options under each category Next give the Ps 5 minutes to generate a menu of options for each of their categories (or at least 1) Then do this as a group using at least 2-3 different examples Aim to get at least various options for each category Acknowledge that client won’t go away and work on all of this, but the list needs to be longer than what the client goes away with in order for the client to have enough options to choose from. Debrief: Click again to show the next question and ask the participants. (ask first, then offer, invite to write, client first, menu of options) Which practice principles and techniques would you use if doing this with a client?

Practising step 6 Create a personal goal for a client
Choose one option from the list you just created Formulate a client goal in 1 or 2 sentences including: What they are going to do When or how often (frequency per day/week/month) the action will be carried out Quantity/duration/intensity of behaviour as appropriate Start date, review date &/or completion date (Note from AKR: Notes need to be updated) T: We’re practising step 6: Formulate a personal goal from one of the options you just created. Allow a 2-3 minutes. This is not about creating your own goal, although you don’t have the patient in front of you, you’re putting together a goal statement using this format (criteria on slide) Debrief: Ask self-selected participants to read out their client goals and correct them as required by asking questions and/or by asking the other participants if they think the goal meets the criteria on the slide. If not, use some prompt questions to make it meet those criteria, e.g. when and how are you going to do this? Try to select a range of client goals to be read out: exercise, nutrition, another topic, a one-off goal etc. (G )

Phrasing for steps 7-10 – small group exercise Normalising and addressing barriers to action Identify barriers Address barriers How do you raise the topic that it’s normal for things to get in the way of your plans? Create a menu of barriers from BEST to help the client to identify their own below the line barriers. What questions can you ask to get the client to come up with the solutions? How could you use a menu of options to suggest strategies to address the barriers? P: To generate sample phrasing for steps 7-10 This slide is animated. T: Yesterday we did this for one of your own goals. Now you are going to work in small groups to generate sample phrasing for identifying and addressing barriers. Because we know things are going to get in the way, we want to normalise this for our clients. Small group activity Work with the personal goal relevant to your clients or one that your clients commonly struggle with The one you generated for step 6 This first part of the exercise is to come up with phrasing using the client first technique and menu of options to help the client identify the what might get in the way for them (what did you ask to identify your client’s barriers). Refer to pages 140 – 141 in the guide to guide you through the exercise. The second part of the exercise is to think of phrasing that would help the client come up with solutions to those barriers. Identify barriers: Most of which relate to thinking and planning barriers Address barriers: How will you address the thinking/planning barriers Invite the client to write these down, particularly if it’s a thinking strategy, as they might forget what it is when it comes time to use it. Give participants 10 minutes to do both parts. (G )

Share your phrasing examples:
Normalising and client first for barriers Menu of options for barriers Client first for strategies Menu of options for strategies P: Debrief for steps 7-10 exercise T: Who would like to share examples of their sample phrasing? Debrief: What are some of the common barriers that people might come up with? What would you say if someone says “well I don’t have time”? (Can you make time, given that you’ve said that you want to to work at this? Is there something you could NOT do to give you time to work on this?) Link the personal goal to the action plan, show example in participants handouts and page 153, Appendix K in the Guide Remind Ps that they wrote their personal action plan on a blank piece of paper on Day 1s exercise, and the prompt questions used previously are the same questions they could use (slide 67, also in participants handouts). Stick the BEST white card on the bottom LHS of the generic behaviour pathway. Invite the client to write (G137, 140, 144, 147)

Documenting Steps 6-10 Treatment category: Regain and maintain mobility Personal goal: Do my rehab exercises 3 times per day starting from tomorrow at home and continue doing them until I see the physio again Actions required to achieve this goal: Tick when completed Put my next rehab appointment on my calendar in the hallway Put my rehab exercise handout and rolled up towel on the bedside table Set an alarm to take my pain meds before the exercises Do my exercises before I eat breakfast, lunch and dinner Prepare my meals before I do my exercises Label a pack of frozen peas with a texta and use as an ice pack Put a damp towel around the peas & apply to my knee during my meals Make sure I put the packet of peas back in the freezer after use Remind myself that even though it hurts while I do my exercises, the pain will settle afterward and it’s not causing damage  P: Documenting below the line process T: This is away of putting the below the line steps together Place after Step 8 slide – intended to highlight the importance of checking confidence and checking for cognitive barriers that need to be addressed. Rob who needed to work on pain management How much do you want to achieve this goal? (Not at all) (Very much) How confident are you that you can achieve this goal? (Not at all confident) (Very confident) X

Video – Young Geoff Consultation showing the whole framework in 13 minutes Video - young Geoff – 13 mins, split at 7 mins (decision line) P: Shows a short consultation using the HCA practice principles, essential techniques and 10 step decision framework T: I am now going to show a video that puts all of the things that we have learned about the HCA approach into a short consultation of 13 minutes. The client is a young man with diabetes who has experienced some acute episodes due to drinking too much alcohol. This is a real patient and a real situation (even though we saw the client earlier in a mocked up situation that showed what not to do). This consultation was filmed first. Your task is to write down the practice principles and techniques that you observe. Look at the practice principles and essential techniques on the A5 white cards as you watch the consultation. I will stop the video part way through to discuss where we are at in the framework. Young Geoff 13 minute video

How can you adapt your clinical practice?
Clinical tasks Description Set-up & introduction Assessment Lifestyle & treatment recommendations Passive treatment Broad macro level education Prioritisation of recommendations Targeted micro level education Personal goal setting Personal action planning Treatment planning/referral/other P: To help participants to apply the HCA approach to their own clinical or program context T: We are now going to spend a time discussing how common clinical tasks can be adapted to be consistent with the HCA approach. Spend about minutes on this. In the left column on the slide are a number of clinician tasks. How would you adapt these to be consistent with what we have discussed in the workshop? Refer to Appendix A, pages 15 and 16 in the Guide: Instruct participants to read the table and tick any that might be useful to apply to their own clinical practice. Tick what you’re doing and circle what might be useful. 5 minutes to read through What are you doing that accords with this approach, not assuming you’ve only just (G Appendix A, p )

Skills development exercise: Group exercise
Discussion topic: Will you work on developing your skills to apply the HCA approach in your workplace? Work through decisional balance as a group If you cross the decision line write down strategies that might help you to address any challenges and implement the approach P: To attempt to transfer learning from the workshop into practice in the workplace. To create an action plan/skills development plan for participants to put into play when they return to work. This slide is animated T: Now that you have learned the HCA approach, and so that you don’t waste the time that you have spent in this workshop, our final exercise is to come up with a goal and a plan for how you might implement your new knowledge and skills back at work. Each one of you will be different in what you take away from this workshop. Clinicians who are already skilled in facilitating behaviour change may take away a few additional useful tips. On the other hand, some of you who are new to HBC might have ‘messy head syndrome’ right now. This exercise should help you to decide what you are going to do with the material that we have presented over the last two days, if anything. We make no assumptions about how ready or willing you are to do this, so please be honest when working through this exercise. The decision that we invite you to consider is Will I implement anything from this 2-day workshop into my clinical practice? If the answer to this question is ”yes”, you can go on to develop a personal goal and action plan for how you will do this. If you are ambivalent about doing this, then this is an excellent opportunity to practise decisional balance! Participants may wish to conduct this exercise as a: Group In discipline-specific small groups Partner with those next to each other. Allow 10 – 20 minutes depending on the group Encourage participants to start off with decisional balance, even if their importance is high. This will be an opportunity to the practise decisional balance technique To get some ideas about what you might do to increase your skill level or implement the approach, review your self-ratings on your self-appraisal form (PP and ET) See also the extended facilitators’ workshop notes for additional information.

HCA generic behaviour change pathway
Knowledge & understanding Motivation & expectations Decision & commitment Decision Line Planning P: To remind participants of the generic behaviour change process, and give them a brief summary of the practice model they have been shown that helps them to facilitate behaviour change. Note: this is also to give any staff given the task to present what they have learned to other staff a way to accurately and briefly describe the our HCA approach. T: Yesterday we started off talking about how people naturally follow this sequence when they take action to self-manage their health. However, we also know that people will get stuck along this pathway and hence will not take the actions that would get them better health or quality of life outcomes. Along with the Generic Behaviour Change Pathway, which is on the inside cover of your guides (indicate), the HCA approach incorporates four key elements that enable clinicians to facilitate this pathway in a systematic and time effective manner. These are: The Practice Principles, which enable practitioners to embed client-centred communication into every consultation with clients; The BEST barriers concept, which allows practitioners and patients to better identify and address common barriers to change both above and below the decision line; The Essential Techniques, which are utilised either in all situations or in particular circumstances to enable patients to progress towards successful change; And the Key Questions, which represents the clinical decision making to bring all of this together. You have all of these elements in your Guide and on the two white cards (hold up). These can be used to quickly summarise our approach to any other staff who would like to know what you have worked through in our workshop. Action Self-regulation Build Motivation Build Confidence

Troubleshooting with clients
Difficult clients: client is above the decision line Chronic and complex clients: client is above the decision line client has significant BEST barriers messy head syndrome for clinicians and clients When you are feeling stuck, ask yourself: Is the client above or below the decision line? What is the sticking point? Which course of action is appropriate? P: To provide some simple guidelines that can help clinicians to troubleshoot This slide is animated T: When you know that something is going on for a client and you feel stuck, here are some general guidelines that may help you. Firstly, think logically about the client Having what clinicians commonly call a ‘difficult client’ usually means that there is a barrier that is stopping the client from moving forward – generally they are above the line. Chronic and complex clients usually have messy head syndrome and this can give clinicians the same feeling because they have so much going on. They can also be stuck above the line and/or have significant situational or psychosocial issues. Secondly, by asking RICk, it can help us to work out why the person is ‘difficult’ e.g. is it a lack of motivation, is it knowledge or do they believe they can’t do it i.e. low self efficacy. Whenever we are feeling stuck, firstly think ‘macro’ i.e. is the client above the line or below the line? You can then go ‘micro’ and work out which step they are at and what the barrier is. You can then work out what technique that you may need, which includes education. Is everyone clear with this? The HCA 10 step decision framework helps us to troubleshoot what the issues are in a consistent, time efficient manner

HCA skills development pathway
HCA Core Training Part 1 (2-day workshop) HCA Peer Leader Support Package HCA Peer Trainer Program (Train the trainer option) HCA Core Training Part 2 (1-day workshop) HCA core training for clinicians Organisational capacity building options HCA Core Training for Managers (1/2-day workshop) P: To show how HCA supports skill development T: You have just completed core training part1, developing your skill will take a little practice Read through the skills development pathway. In particular, practising after the workshop and attending further training i.e., Core training part 2 in 3-6 months time.

How confident are you that you can use the HCA approach in your work?
Practice principles Essential techniques: For use with all clients: Client first technique Menu of options technique Using your RICk radar Optional use to identify & address barriers: Asking RICk Decisional balance technique Turning ANNTs into PETs Tracking and monitoring strategies 10 step decision framework P: To link into the workshop evaluation form by asking participants about their confidence level. These confidence questions are included in the evaluation form. They will be processed for research purposes as well as workshop improvement. This slide is animated T: (read the title) Ask the participants to reflect on where they are now with their confidence and what they are going to do to increase this if necessary, or to generally embed the HCA approach into their work. Remind participants that the PP, ET and decision framework (above and below the line) are on their white cards. If participants are still low in confidence, you can discuss strategies arising from the practical exercise or come up with some new ideas through discussion across the room. Advise participants not to leave until you wrap up the workshop and they receive their certificates.

(G 25) P: Soft and encouraging ending
T: If we had a client who was feeling low in confidence to manage a change, we would encourage 1 thing at a time. It’s no different for ourselves. Encourage clinicians to make small manageable changes and get support (G 25)

Thank you for your participation!
Download case studies, session records, practice guides and worksheets from the Resources Library at Our tools can be used freely in clinical practice and programs as long as HCA intellectual property is visibly acknowledged Thank you very much for your participation Note: Hand out certificates and ask people to fill in both sides of the evaluation form please.

Client case – ‘toxic wasteland’
Male, mid-30’s, BMI = 34 (96 kg), elevated BP, BGLs & Chol., married, 2 children, manager in hospitality industry Told to change diet, lose weight, start exercising, reduce alcohol and caffeine dramatically, quit smoking: 18-24 shots per day espresso per day 1 bottle of wine per night, plus multiple martinis 15 cigarettes/day Low energy, poor sleep, frequent waking, needed naps on days off Very little water – doesn’t like it No exercise, poor diet, hardly any fruit and vegetables

Client case – 1 x 20 minute intervention
Reaction to Dr’s advice: “What can I do? I would have to quit my job!” 1 x 20 minute impromptu conversation in Nov 2009: High importance, but low readiness due to very low confidence in making any changes One thing at a time, one step at a time, adding up over time Client chose alcohol reduction as a priority Planned to eat dinner early with family (doesn’t drink when children are up and drinks less if he eats first), and not keep any chilled wine in the house No review consultation

Client case – behavioural changes
1.5 years: 5 alcohol free days/week, 1 bottle of wine over 2 nights, no martinis No more than 2 x skinny lattes per day 2-3 cigarettes per day, work days only 1.9 lt jug of water/day (hot water + ice + touch of cordial) 1 x vegetarian meal per week, aims for daily vegetables + 2 x fruit per day 3 x per week on exercise bike, plus conscious use of (many) stairs at work No longer takes naps on days off 2.5 years: 5 serves vegetables plus 2 serves of fruit per day 5 x exercise sessions per week

Client case – physiological outcomes
Results at 1 & 1.5 years: BMI 29 (82 kg) - previously 34 (96 kg) BP, BGLs and Chol. in normal range – previously all elevated No longer gets daily headaches Sleeps through the night and reports increased energy Results at 2.5 years: 76 kg Waist circumference 88 cm (previously 110 cm BP, BGLs and Chol. All in normal range

Client case – intrinsic motivators
Dreamt he had to watch his daughter’s wedding on video due to ill health – used this mental imagery to motivate himself “I couldn’t be there for her on her happiest day” Can feel and see the difference that his healthy choices have made and wants to maintain these benefits Work colleagues have commented on the visible changes He reports that he doesn’t miss his old habits The first 3 months were the hardest

Client case – client reflection
“What the Dr told me to do was impossible” “I am thankful that she told me (about the critical nature of my health issues) but I expected more help with how to do it” “The Dr doesn’t know why I do what I do and why it is hard to change. Health professionals need to know why!” “I was in a nasty evil cycle” Links back to slide 53. Summarise Derek? Why do we show Derek. Embrassed the principls: One step at a time one thing at a time and trial and wrro Incremental xxxxxx

Teach a man to fish

Presented by Angela Kinsella-Ritter

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Presented by Angela Kinsella-Ritter

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