AN
OVERVIEW OF WHAT YOU COULD LEARN Section
I explores how cultural, personal and professional issues affect the change
process in patients. Scientific rationality lacks sophistication in addressing
human irrationality and in dealing with otherwise knowledgeable patients who lack
the critical factor: motivation. Chapter 1 highlights
the limitations of the rational, scientific approach in providing health information
and advice to patients about changing their unhealthy behaviors, and explores
key concepts, models and ideas for addressing common, everyday situations. Chapter
2 offers a case study that contrasts the advice-giving or fix-it approach
with a motivational one. The aim here is to highlight the merits of adopting a
motivational role. Chapter 3 explores the implications
for patient change based on which role you adopt-the fix-it, preventive or motivational
one. Each of these roles is defined according to its characteristics, functions
and boundaries to examine how they differ in helping patients change their behavior.
Chapter 4 examines how assumptions can help or hinder
the change process for the patient. Section
II is an overview for understanding and facilitating individual change.
Using a Forces of Change model, you learn how both individual and systems factors
can generate positive and negative forces for change (Chapter
5). More specific attention is then given to understanding the individual
dynamics of resistance (Chapter 6) and motivation
(Chapter 7) from different perspectives. These three
chapters help you become familiar with the key theories, models and concepts that
have shaped the development and practical applications of the six-step approach.
To prepare for using the materials in Section III, Chapter
8 is an overview of the six-step approach with an example of a practitioner-patient
partnership working toward behavior change and using this approach as a mental
map for thinking about how to motivate behavior change.
Section III (Chapters 9-14)
describes in detail the six-step, interdisciplinary approach for negotiating behavior
change with patients. A chapter is devoted to each of the six steps, describing
micro skills that you can use for addressing a broad range of health behaviors
in health promotion (e.g., physical activity), disease prevention (e.g., smoking
cessation, regular mammograms), chronic disease management (e.g., diabetes) and
injury prevention (e.g., the use of car safety belts). Though you will become
familiar with a wide range of micro skills used in this method, you still need
to learn how to use these skills in an effective, patient-centered way.
Section IV (Chapters 15-17)
specifically addresses tobacco use, excessive alcohol intake and self-care of
diabetes. Consider doing an in-depth study of a specific behavior so that you
can learn how to generalize this approach to other behaviors. You can also use
these chapters when you get stuck with patients to identify new ideas for interventions. An
interdisciplinary note
I use the term practitioner to describe
all professionals who help patients to change: physicians, physician assistants,
nurse practitioners, nurses, psychologists, therapists, community and public health
workers, social workers and allied health professionals. All members of your health
care team can benefit from learning how to become motivational practitioners and
can adopt a variety of roles when working with patients. In the examples and stories
in this book, I have used the abbreviations FP, PP or MP (and Dr. F., Dr. P. or
Dr. M) to represent the fix-it, preventive or motivational role for practitioners
(and physicians). In the text of this book, I have used
the first person (we) and second person (you) to describe the fix-it and motivational
roles, respectively. As practitioners, we all assume the fix-it role, but when
it is not working, you can opt for adopting a motivational role. This personal
style of writing sets a tone that aims to engage you in the change process in
ways that you may replicate with your patients.
HOW
TO USE THIS BOOK
Motivational skills are fundamental
core competencies for all health care practitioners. Yet this topic is inadequately
or poorly addressed in health care education. Instead, you are left to learn on
the job. This book could have a cascade of positive benefits on your continuing
professional development by
•
Reducing your frustration in working with so-called resistant patients
•
Enjoying engaging patients in dialogues about change over time
•
Developing individualized approaches to meet patients' changing needs
•
Enhancing patients' readiness to change
•
Improving patient outcomes Ideally, you would use a variety
of ongoing learning opportunities to enhance your motivational skills over time:
self-directed learning; online group learning; longitudinal skills-based training
opportunities in small groups led by supervisors or facilitators; direct observation
with simulated and actual patients with feedback and evaluation; and in-depth
learning experiences working with a small number of patients on behavior change
over one to two years. You can use this book to
initiate the process of creating a learning portfolio. The story about the race
between the turtle and hare is an apt analogy for understanding different ways
of using the book. If you race through this book (like the hare), you may only
gain a superficial understanding about individualizing interventions for patient
care, and that limited understanding may constrain your ability to enhance motivational
skills. On the other hand, you can use the way of
the turtle: take your time in reading this book and learn more from your journey
as you go along. Experiment in applying new ideas and concepts in your clinical
work and learn from those experiences. Introspective journaling can further enhance
your continuing professional development. This process of higher learning (as
described by Dr. Lonka in Foreword 2) can help you gain an in-depth understanding
about how to enhance your ability to engage patients in change dialogues. However,
many practitioners are reluctant to engage in such a learning process because
it takes hard work to change (just like our patients). To
assist you with this learning process, each chapter begins with a question or
brief statement that helps you focus on what you can learn from reading this chapter.
Case examples and learning exercises are provided throughout to help you better
understand key concepts, principles, strategies and interventions for motivating
change. Questions are also posed at the end of each chapter with space given for
writing a summary about your new learning and its potential impact on working
with your patients. This book invites you to journal your learning process about
changes in yourself and in your clinical work. Consider using the PARE improvement
cycle as you read (and hopefully revisit) chapters of this book over time.
•
Prepare: Set a flexible
timetable for reading these chapters that gives you time
to
experiment in applying new ideas and concepts in your clinical work.
•
Act: Consider highlighting
areas with a yellow marker and making notes in the
margins
to help you write summaries for the next phases of the learning cycle.
•
Reflect: Write a summary
(in 200 words or so) about what you learned that was
new
for you. Write in the first person (I) about your internal reactions to the
material
rather than reiterating the text of the book (it).
•
Enhance: Write down your
ideas (in 100 words or so) about how your new learning
could
improve what you do with your patients. These
notes will help you gather personal evidence about your continuing professional
development. For example, your notes may refer to changes in your mental maps,
your understanding about your assumptions and roles and the potential application
of new ideas, metaphors, concepts, models and theories. You can add these notes
to build your learning portfolio. Whether or not you are willing to make a commitment
to this journaling process, you can still assess whether you gained any of the
benefits mentioned on the previous page. Whatever you decide, this learning process
needs to be considered within a much larger context. AN
ECOLOGICAL PERSPECTIVE An ecological approach to engaging
and activating individuals, families, organizations, communities and systems is
needed to promote healthy habits and self-care of chronic diseases at multiple
levels. Such an approach integrates macro (policy), meso (organizational) and
micro (individual) strategies with multimodal methods to generate synergistic
collaboration among the top-down (political and administrative), side-to-side
(intersectoral) and bottom-up (grassroots) processes.18 A brief description of
these strategies provides a wider context to understand the complexities of disseminating
motivational practice into health care and the contributions of this book toward
this overarching goal. MACRO STRATEGIES
Changes in political vision, leadership and public policies
establish national organizations to
•
Shift the health care agenda and resources from an acute cure paradigm toward
health promotion,
disease prevention and disease management
•
Enforce national and international laws and policies to reduce risk behaviors
(e.g., the
Framework Convention on Tobacco Control)
•
Align financial incentives to quality improvement initiatives in health promotion,
disease
prevention and disease management
•
Develop clinical information technology systems to analyze how process improves
outcomes
at population-based levels
•
Provide data about improvements in performance at organizational and
practitioner
levels
• Use marketing
strategies to promote the transformation from a disease-producing
to
a health-promoting society
•
Foster the development of intersectoral approaches, community mobilization and
grassroots
programs MESO STRATEGIES
Changes
in public policies provide the necessary learning resources to support the continuing
professional and organizational development that is needed to enhance health promotion,
disease prevention and disease management programs across health care settings,
schools and work sites. Such programs enable practitioners to learn how to •
Contribute toward a continuous improvement of their comprehensive programs
•
Change from the fix-it, advice-giving role to the motivational role
•
Enhance their motivational skills over time
•
Link up with community mobilization initiatives and grassroots movements MICRO
STRATEGIES
Changes in the organizational setting,
teamwork, professional roles, workflow and clinical information systems are developed
to •
Use a spectrum of methods (as described at the beginning of this section) and
develop
individualized interventions to meet patients' changing needs.
•
Use a variety of delivery methods (e.g., individual encounters, group visits,
telephonic
support and online learning programs)
•
Encourage the general public to systematically use mutual aid and self-help
(MASH)
approaches to behavior change, with or without professional support Even
with ideal political leadership and public policies supporting this ecological
approach, individuals ultimately determine the impact of any systematic approach.
The quality and effectiveness of the individualized interventions will determine
the ultimate success of any program. We cannot wait until such ideal public policies
exist before learning how to motivate patients to change their unhealthy habits.
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