By Nick Nielsen and Dr Doug Hing, Lead Trainers at OSCA
Mr Z has been called in to review his diabetes. You see that he is overweight and smells of cigarette smoke. He’s missed most of his specialist appointments and his blood results show things are getting worse despite recently starting another medication. His past records show that he has been told many times to eat healthily and to exercise more. He has a young family and his job often involves working late shifts which he has always said made it impossible for him to exercise regularly or eat healthily.
Does this scenario seem familiar? For many health professionals, significant numbers of the patients and clients they see don’t seem to take enough responsibility for their health despite all the risks. There may be things in the way which may lie outside the health professional’s immediate sphere of influence, such as personal choices and social issues.
What is the likely reaction for the health professional? It could be frustration, it could be annoyance, but the heart of it is likely to be the feeling of powerlessness – the health professional’s powerlessness to say or do anything that would, in their view, improve the patient’s health.
The sense of powerlessness is often difficult to recognise and not something we typically welcome. We don’t want to be reminded of life’s unpredictability, nor the lack of control we have in so many areas on a day-to-day basis.
And health professionals are under a great deal of pressure, particularly as there is a powerful cultural expectation that the role of the health professional is to ‘fix’ things. We also care and want to help.
So, what might be a health professional’s reaction to their own sense of powerlessness in a situation with a patient? Where they feel the patient isn’t taking sufficient responsibility, it’s natural for the health professional to want to step in and try to rescue the situation by taking control.
Interestingly, a similar dynamic may be happening for the patient or client.
Having a chronic condition can be significantly life changing and can cause feelings of powerlessness. Patients may feel they don’t understand the process – what happened, what it means, what will happen in the future and the likely risks. It can be easy to imagine the worst, even at a subconscious level, which can prompt a great deal of fear and make it difficult to face the situation. A natural reaction is to try and shut out the situation and remain in the safer present day, even though this may pose profound risks to long-term health.
A patient feeling powerless is likely to withdraw and avoid engaging with both their situation and the conversation, which can mean health professionals feel powerless in turn, prompting them to try and step in and take control. The more control health professionals try to take, the more pressure patients can feel, increasing their (often subconscious) experience of fear, and the associated withdrawal and resistance.
From one perspective, when it comes to managing long-term conditions, health professionals can be considered to have very limited power. If a specific conversation about behaviour change lasts ten minutes, that leaves 6,710 minutes for the patient to have on their own in a waking week to make changes (assuming they sleep eight hours a day and that there is contact weekly -which is often not the case). The key decisions and actions that affect the patient’s health outcomes happen in the 6,710 minutes of that week, not the ten with the health professional.
So, while shared decision making and other ideas of the health professional ‘empowering’ the patient has been around for years – a key question is: how much power and control did the health professional have in the first place?
Our answer is: not a great deal. While this may be a challenging realisation due to the discomfort that come from the sense of powerlessness, it can ultimately be very freeing.
Because, if health professionals are able to accept the limitations of control they actually have, it frees them up to have a different, more personalised kind of conversation, and also to relinquish the expectation that it is up to health professionals to fix things. It means that, whilst health professionals don’t relinquish their care for the patient, they can take a step back.
And by taking a step back, space can be made for the patient to come forwards.
While we might expect that stepping back diminishes the sense of urgency in the situation, and therefore the likelihood of change, it tends to have the opposite effect. By stepping back and doing more asking than telling, we can achieve more engagement, increase satisfaction and improve health outcomes[1].
However, this is easily said, and not quite so easily done.
It all starts with ourselves. First, it is important to recognise and accept the powerlessness in the dynamic of the health professional with the patient. No matter how much a health professional cares, how many good ideas they have or how knowledgeable they are, ultimately the patient will only change if they want to, and when it comes to lifestyle behaviour change, many people already have a pretty good idea about what they ‘should’ be doing.
So, how do we come to terms with powerlessness?
At a theoretical level, it can be helpful to recognise the limitations of our power. For example, the lack of time available in the conversation between health professionals and patients; the limited impact of all the advice and ‘telling’ over the years; the many other influences on the patient (including other health information and mis-information); and our understanding of how easy it is for us all to avoid changing especially if there is underlying fear.
At an emotional level, it’s useful to notice our feelings of powerlessness. For example, when we become frustrated, angry and/or confused by a lack of change. This can be particularly pronounced when there is an expectation of a solution or ‘fix’ and the associated sense of ‘failure’, potentially by both the health professional and patient, when the behaviour has not changed.
Being aware of the expectations that often exist helps to highlight a fundamental component in supporting us to open up these situations.
Safety: as it is the sense of fear and powerlessness which makes all of us avoid our issues, then it is only a sense of safety which will help us confront them. Even in limited time, it is incredible the sense of safety and space that skilled professionals can create.
Crucially, for health practitioners to relax their expectations of themselves and relinquish their sense of control, they need to provide for themselves what they try to give to their patients: the sense of space and safety. The space and safety from their own unrealistic expectations of themselves.
How is space and safety created?
First, it’s about the health professionals. Then, it’s about the patient
It starts with the recognition of the limited control health professionals have over their patients’ lives. And then it is about learning to be comfortable emotionally with this knowledge, whilst recognising all the factors that make this difficult and may prompt a professional to try and step in and fix things for the patient instead of making space (whether it be pressures due to a lack of time, targets, hunger, fatigue, mood and even stressors from colleagues or home etc.).
If these challenges and limits can be identified, we all can begin to feel more comfortable with them. Because, in situations like the patient scenario described, there is no ‘right answer’, there may be no immediate results. Doing this consistently, whether in the moment or afterwards, can help develop a level of comfort, making it easier to breathe in the moment, and to settle the need to control and fix.
So instead of getting things ‘right’, the aim has to be to create as much of a safe ‘transformational space’ for conversations as possible. This often means recognising that it is a journey, and ‘results’ may not happen in just one conversation.
Next, it’s about understanding and empathising with where the patient is. This empathy helps to build the sense of safety as quickly as possible – to maximise the transformational impact of the conversation. Without safety, a patient cannot be honest with the health professional or even with themselves about the risks they face and what they may need to do about it.
Ultimately, it’s about health professionals and patients
Health professionals are experts in their field of speciality. Patients are experts in themselves, their situation, their values and their preferences. Consequently, it is crucial for health professionals and patients to come together and explore these values which will ultimately determine what advice will be taken and what changes will be made. In these situations, the limitations of the health professional’s power is managed by utilising the patient’s power.
Building safety by establishing trust and rapport
At OSCA, we have been delivering a personalised care programme called Coaching for Health[2] since 2011. We have trained thousands of health professionals in various roles across health and social care. In partnership with our participants and trainers, we have strived to hone our curriculum down to the essentials required for creating transformational conversations. Safety through trust and rapport, while simple and not new, continues to arise as one of the core components of an effective approach.
An enabling mindset
In our courses, we discuss a number of core principles which form the fundamentals of the approach. These describe the philosophy and mindset or attitudes we recommend health professionals embody in conversations with their patients. Importantly, these principles are not truths and do not guarantee any particular outcome. However, they can be considerably helpful as an approach to conversations, particularly in situations where there is a sense of powerlessness.
Below is a brief exploration of our first core principle which is fundamental for building safety by establishing trust and rapport.
Principle 1 – ‘Where the patient is now, is OK.’
This means, irrespective of where the patient is at the start of the conversation, the health professional sees them as ‘OK’, even if they are not ‘OK’ in the professional’s opinion and/or in the patient’s. This does not mean accepting and not challenging an inappropriate situation or not wanting or hoping for improvement or change. Instead, this principle is about seeing behaviour change as a journey and that it is ‘OK’ for the patient to be at the beginning of this journey.
Why not simply say ‘non-judgemental’? Because we believe we need to go further. The challenge is that we all judge, all of the time. We can’t avoid it and the triggers described above often exacerbate our judgements.
This principle recognises also how much our patients may feel judged already, if for example they are not following all the advice given to them by other health professionals. Many patients will feel judged by the very institution health professionals represent, before they meet or even talk to the professional.
So, we often need to go further than just being non-judgemental. We call it a ‘radical acceptance’ of wherever the patient is – whether they currently want to change or not. If health professionals can use all aspects of their communication (verbal and non-verbal) to convey to the patient that they are safe where they are, in that moment, and that they are not going to be judged regardless of what they are or aren’t doing, then there is a greater chance of honesty and potential for change.
The benefits
In the limited time available for such conversations, it’s hard to find a window to do anything additional. However, if time is invested to build safety in the relationship at the outset, there is likely to be more honesty and engagement, which can help save time in the long run – even if it’s over multiple conversations. Creating safety is foundational to a Personalised Care approach. Both because it shows respect, and also because it is pragmatic as the resulting conversations are likely to be more efficient and effective.
Not only does the evidence attest to benefits for patients and clients in terms of satisfaction and health outcomes, the health professionals we’ve trained and worked with regularly communicate to us how much better they feel about their work. Because they have been able to relinquish the often unrealistic expectations they hold of themselves to fix situations they can’t, there is an emotional liberation and practitioners report enjoying their jobs more. In environments of increasing pressures and significant issues with workforce retention, this is increasingly important.
This is the fifth similar conversation with Mr. Z, and sitting there, the health professional recognises their frustration and the resulting desire to take control but also to give up responsibility by dismissing the patient as impossible to help. After a brief pause to gather their thoughts, the health professional tries a different approach and asks Mr. Z about what he wants to talk about and what is happening in his wider life. It takes some sensitive questioning, but Mr. Z eventually talks about his worries about finances, bullying at work, difficulties sleeping and the struggles his children have with behaviour. The health professional reflects back what they heard and asks what is most important to Mr. Z and what ideas he has. Through exploring this, Mr. Z says that he will make time to discuss matters with his wife and address issues at work.
In the final few minutes, the health professional asks permission to discuss the blood results and asks how Mr. Z is getting on with the medication. With safety established, and new levels of trust, Mr. Z is honest about not taking the medication regularly, but conveys that he knows he should as his condition is not improving. He decides to start taking the medication regularly and to include talking about diet and smoking with his wife who is supportive of making changes. The consultation ends with both parties feeling better and trust established for more fruitful future conversations.
About the authors
Nick Nielsen
Nick is a director at OSCA. He is an entrepreneur, facilitator, trainer and coach, with over fifteen years’ experience of leading and supporting organisations in the areas of behaviour change, organisational development and strategy. Nick regularly delivers Coaching for Health training for a wide range of health and social care professionals, as well as wider communication and leadership skills training to private, public and voluntary sector organisations. For the last ten years Nick has also worked as a personal and professional coach. Nick has coached many people in the social and political sector.
Dr Douglas Hing
Dr Douglas Hing is a General Practitioner in South West London with a background in Coaching, Education and Management. He is a Curriculum Editor for the Royal College of General Practitioners (RCGP) and his leadership and management experience includes being a Clinical Director in clinical commissioning, focusing on making improvements in Merton. He is a Lead Trainer in Coaching for Health at OSCA.
[1] Kivele, K., Elo, S., Kynges, H. and Keerieinen, M., (2014). The effects of health coaching on adult patients with chronic diseases: A systematic review. Patient Education and Counseling, 97(2), p.147
[2] For more information – www.coachingforhealth.org