One of the most challenging roles of a diabetes educator is to help those who seem stuck - those unable to make a specific behaviour change, appointment after appointment. Hopefully this page will help! You'll learn:
- To assess and build conviction in patients, so they believe change is personally important and will benefit them.
- To assess and build confidence in patients, so they believe change is personally achievable
- To use a one page summary tool.
- To NOT be fooled by the smiles! Without adequate conviction (first) and confidence, patients won't make changes, no matter how much they smile at you or how friendly they are.
Imagine you just made a suggestion to this couple. One of them believes it's NOT important. Can you tell which? Me neither...not yet. You can also consider this cartoon video and see if any situations seem...familiar... to you! Overcoming Resistance to Change
What are conviction & confidence (c & c)?
CONVICTION: A belief that something is personally important; it provides personal benefits.
CONFIDENCE: A belief that something is personally achievable.
STEPS for CHANGE. The simplified steps for change include, in this order,
- Believing a behaviour is personally important (high conviction)
- Believing the steps are personally achievable (high confidence)
- Attempting the behaviour change
Of course behaviour change is considerably more complicated than this! However, for our purposes we'll keep it simple and limit it to discussions on assessing and building conviction and confidence.
Here's an analogy: Spouse plans trip
Imagine a spouse plans a trip so that she and her partner can get back on track with their relationship. She wants to know if they should fly or take a cruise there. The partner arrives home to learn of this for the first time.
- Low conviction is like the partner on the left. He isn't committed to the trip; he didn't even know the relationship needed work. He's not conviced of the "what" (the trip) or the "why" (the relationship repair) - yet. He's not ready to talk about the "how".
- Whereas low confidence is like the partner on the right. He agrees a trip would help the relationship, agrees the relationship needs some TLC, but sees some barriers. In other words, the "what" (the trip) and the "why" (relationship repair) are important, it's the "how" of the trip that needs help.
Different actions are needed to move each of these people forward on their trip. This page reviews key steps for educators to help their patients in their journeys of behaviour change.
Ask About Conviction
Consider these questions when assessing how important a patient finds a specific behaviour change. Try not to interpret a patient's smiles, long-standing relationship with you or their lack of dissent as high conviction. Clarifying conviction levels with direct questions is respectful of the patient's preferences, time and efforts. Allowing time for the patient to think and reflect outloud can provide insight into a patient's beliefs about a behaviour, concerns, expectations and ideas about how that behaviour change may impact their life.
- "How do you feel about ____(insert behaviour)?"
- "How do you think ____(insert behaviour) will benefit you?"
- "On a scale of 1 to 10 how important is ____(insert behaviour) to you?"
(...because quite often, the smile can mislead!)
You may need to assess conviction "Higher Up" by asking:
- "How important is getting lower glucose levels to you?"
- "How would a lower A1c impact your dreams for home, work, family?"
- "How would you feel about making medication changes if it could reduce your risk for _____(e.g. kidney or eye damage. Insert the specific complication you feel best connects with the patient)?"
Ask About Confidence
Remember, a patient's smiles don't necessarily mean high confidence. Also, don't assume a patient would tell you they aren't confident, even if you've had a trusting relationship with them for years. Clarify using questions like these when assessing confidence.
- "How confident do you feel about ____ (insert behaviour)?"
- "On a scale of 1 – 10, how CONFIDENT are you that you could _____(insert behaviour)?"
Remember that high confidence does not mean the person has high conviction to change - they may feel confident they could change IF they wanted to. Assessing coinviction first, before assessing confidence, is often the best strategy.
The Order Matters!
Find the Target - Assess 1st: Is it conviction or confidence that needs increasing first?
Aim at the Target - Coach 2nd
When we forget to assess conviction first and assume people are on board with change, maybe because of their smiles and humour, we put the therapeutic relationship at risk. We risk:
- disrespecting patients' autonomy and time
- losing patients' trust
- losing rapport and honest answers; alienating patients
- decreasing our ability to help patients
Case 1: Marta
The diabetes educator asks, “Marta, how do you feel doing some gluocose checks?”
Marta shrugs, then she sighs heavily with annoyance and says, “I used to do that. It will get in the way of my work. I know you need the numbers for the insulin doses but I have to take care of kids for a living. I run a daycare. It’s chaotic. Those kids keep me so busy! And, those kids are much more important than me!”
- Is now the right time to suggest making a goal to start glucose testing?
- Is Marta's conviction for glucose testing low, moderate or high?
- What other question could you ask to clarify how important glucose testing is to her?
- Do you want to build conviction or confidence in her and which specific strategy might you try?
