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, often because it provides personal benefits.
CONFIDENCE: A belief in that something is personally achievable.
STEPS for CHANGE. The simplified steps for change include, in this order,
- A person believing a behaviour is personally important (high conviction)
- A person believing the steps are personally achievable (high confidence)
- A person 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.
Why study conviction & confidence (C & C)?
It's simple. We became health professionals to help people. By using techniques to address conviction (importance) and confidence (achievability) we can better help patients and ourselves.
- make faster behaviour changes
- make more meaningful changes
- empower themselves
- take responsibility for their decisions
- increase rapport with patients
- save appointment time
- decrease frustrations
- increase work satisfaction
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)?"
Assess Level of Conviction
Low: 0 - 3
- Patient lacks knowledge, lacks personal reason or doesn’t truly believe they are at risk if the behaviour is left unchanged. E.g. “My grandfather smoked till age 93 and never had a heart attack. I'd be happy to live to his age.”
- Patient may answer with a number of 3 or less when asked to rank how important the behaviour change is to them. This is an arbitrary number.
- Before asking the patient to do the behaviour, or before assessing confidence, consider conviction building activities.
Medium: 4 - 6
- Patient has textbook knowledge of why change is beneficial, but has no personal reason.E.g. “Smoking is bad because it affects heart health and the risk for cancer.”
- Patient may answer with a number of 4 to 6 when asked to rank how important the behaviour change is to them. This is an arbitrary range.
- Before asking the patient to do the behaviour, or before assessing confidence, you may wish to conviction building activities.
High: 7 - 10
- Patient expresses a personal reason for making the change (regardless of textbook knowledge). E.g. “I want to quit because my grand-daughter said she doesn’t like the smell when she hugs me. She cringes when I hug her."
- May answer with a number between between 7 and 10 when asked to rank how important the behaviour change is to them. Again, this is an arbitrary range.
- This patient is likely ready to make the behaviour change. Consider assessing for confidence first to find and solve barriers.
- Educate with permission. Provide benefits of the behavior change (with permission, so the patient isn't alienated.) The patient may or may not know them. E.g.
- "John, how would you feel about me reviewing some of the ways that starting insulin has helped people?"
- Relate to personal benefits. Discuss how the behavior change could help one problem or one thing of importance that the patient has verbalized (“a benefit carrot”). E.g.
- "John, how would you feel about me reviewing how starting insulin might help with your complaint of being so tired?"
- Elicit change talk. Repeat back statements the patient has made that are positive about the behavior or leaving towards positive.E.g.
- "What made you say 5 instead of 0, when you rated how important this change was to you?" (The person must focus on the positives to answer this.)
- "You said that taking insulin might help you. Tell me more about what you meant."
- Strengthen relationship. Try more rapport building strategies. People will consider more changes if they like you. However, this is not as strong as patients having their own personal reasons/benefits.E.g.
- When appropriate: nod, mirror their body stance, lean forward when they talk, make eye contact, empathize, reflect back or paraphrase their statements, learn more about their resistance to change by asking more open-ended questions
- Ask if patient will consider a “thinking about” goal. This can help the patient indentify a personal benefit of high enough value to consider the behaviour change. E.g.
- "John, you said you didn’t want to take insulin right now. I respect that. I want to be sure you’ve considered all your reasons for not starting or for starting insulin. Sometimes when making big decisions, like buying a car or house, we make a list of the pros and cons. How would you feel about making a list of the pros and the cons that insulin could bring to you and your family’s life today, next year and a few years from now?"
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.
Assess Level of Confidence
Low - Moderate: 0 - 6
- Consider confidence building activities
- Consider "planning" goals
- Consider "doing" goals
Increase Confidence (if adequate conviction!)
If a person has high conviction, but their confidence is low (eg.< 7/10) consider confidence building strategies.
- Help patient identify barriers and solutions. E.g.
- "What would get in the way of you_____ (insert behaviour)?" or "What is the hardest part about ____ (insert behavior)?"
- "How do you think you could work around that barrier?"
- "What needs to change to make it possible for you to ___(insert behaviour)?"
- Focus on prior success. E.g.
- "What helped you _____(insert the specfic behavior) in the past?"
- "What worked in the past to help you succeed with a difficult change?"
- Add social supports. E.g.
- "How would you feel about asking a friend or family member to support you while you make this change?"
- Make a SMART goal based on stage of change. E.g.
- A "Preparing" Goal:
e.g. A goal to 'prepare to' exercise?
"You mentioned you have a treadmill in the garage, but don't know where in the day to use it and where in the house to put it. A goal could be to analyze your options before our next visit and before you start exercising. What do you think?" (Interestingly, some patients will stick just to this goal; others will do it and then jump to exercising as their readiness to change has increased.)
- A "Doing" Goal:
e.g. "How would you feel about setting a goal for doing some exercise?" Depending on the answer, you could set a SMART goal for action.
- Letting Patient Decide:
When uncertain what goal to suggest consider saying something like, "We've been talking about exercise. Between now and when we meet again, I'm not sure if you'd like to:
- think about the pros/cons of exercising some more
- do some planning, to figure out when, where and what you'd do for exercise
- or start exercising?
- "What do you think you are ready for?"
(Remember to wait for their answer. Sometimes it takes a while for patients to process this quesion and how they feel about it.)
- think about the pros/cons of exercising some more
- A "Preparing" Goal:
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
Other Client Centered Skills
- Acceptance and respect: Accept the patient and their choices without judgment. The patient is able to discuss feelings/actions without worrying about rejection or being admonished. We repect the patient's right to make decisions for themselves. We would like to provide more context and information to help them with their decisions, if they are agreeable.
- Empathy by using:
- Active listening - reflect feelings for clarity; repeat key words/phrases or paraphrase; summarize. If a patients repeats elements of a story, it is usually because they feel they are not being listened to.
- Body Language: Facing patient and eyes on them; leaning forward
- Open-ended questions
- Tone of voice: Not hiding behind a professional facade
- Pointing out incongruence: E.g. "On one hand, you feel/know___, and on the other you are doing ___." Give patient time to think about it and respond.
- Virtual Care by phone or video has challenges. We can't always see fidgety nervous hands and microexpressions in response to things we as educators say. Tools we rely on in person may not be seen well by the patient or interpretted correctly (e.g. nodding, leaning in to show we are listening, making meaningul eye contact.) Consider:
- Angling your camera so it appears you are looking at the person, to make a better connection.
- Using more reflective or active listening. See a few bullets above.
- Using appropriate gestures, expressions, varied tone of voice and pauses
- Asking more assessment questions about their thoughts
- Asking the patient if they'd like a more convenient time for an appointment if they appear to be distracted.
- If you are repeating things visit after visit - consider assessing conviction.
- If the patient keeps repeating things in a visit, they likely don't feel heard on that point. Consider active listening.
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?
Case 2: Kareem
The diabetes educator asks: “Kareem, how do you feel about doing some glucose monitoring?”
Kareem answers: “I used to do it regularly. I had a whole system. I think it helped fine-tune my meds back then. Also it kept my wife off my back if I tested, haha! She’s always worried about me so I tried to test to keep her happy. I really feel bad when she worries. Ya. I could definitely do better - my wife wouldn’t be so concerned then and I wouldn’t feel guilty for making her worry. I’m sure I would learn a lot and feel better too.”
- Do you think Kareem has low, moderate or high conviction to monitor glucose?
- Do you want to work on building conviction or confidence with him?
- Pick one:
Of course many strategies can work, we're only wondering which you might try first given what he had to say above.
- Case 3: Ava
During agenda setting Ava insists she wants to know how to eat to increase her energy level. It’s important because she falls asleep while trying to read bedtime stories to her kids. She also wakes a few times in the night to pee, then oversleeps so the kids fend for themselves at breakfast. She wants to be a better mom and spend more quality time with her kids.
Her A1c is 11.7%. She’s taking all diabetes medications that she can (other than insulin). They are at max doses.
You don’t think diet will work. You think she needs insulin.
What can you ask to assess her conviction for starting insulin while...
- Acknowledging her current goal and her concerns
- Upselling insulin. Relate it to what’s important to her and to her current problems.
- Not alientating her. You don’t want to tell her she’s wrong and diet won't help. She's given this a lot of thought and bought healthier foods.
- Not misleading her. You don’t want her believing that the considerable work of diet changes will address the problem fully. You want to be transparent that it may help a bit, may not help enough and may not help at all.
- Showing you care.
Activity: Using your own words, draft a script for yourself that:
- meets the criteria above
- asks a question to assess her conviction to start insulin
- is comfortable for you to speak out loud (try it on your class partner if this is a workshop).