Conviction and Confidence

Assess Level of Conviction

Below relates to a scale of 0 to 10 (low to high conviction)

Low: 0 - 3     lacks knowledge & lacks personal benefit

• Doesn't 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.”
• What to do?    Try conviction building activities FIRST, before asking them to to do the behaviour, or before assessing confidence (before addressing barriers). 

Medium: 4 - 6    has knowledge yet lacks personal benefit

• Patient knows some textbook reasons, but doesn't share a personal reason.
  E.g. “Smoking is bad because it affects heart health and the risk for cancer.” No emotion. 
• What to do?   Try conviction building activities FIRST, before asking them to to do the behaviour, or before assessing confidence (before addressing barriers)

High: 7 - 10     sees a personal benefit to change

• 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."
• What to do?  This patient is likely ready to make the behaviour change. Consider assessing for confidence next, to find and solve barriers.  

Increase Conviction 

1. 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?"
2. 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?"
3. 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."
4. 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
5. 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?"

The Order Matters!

1. Find the Target:  Conviction first or Confidence?
2. Aim at the Target - Coach 

 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. 
• Reminders:
  
  • 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 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!”

1. Is now the right time to suggest making a SMART goal to start glucose testing? 
2. Is her conviction level (belief of personal importance) for testing glucose high?
3. What other questions could you ask to clarify how important glucose testing is to her? 
4. On the one-page Big Summary: An Easier Way to Promote Change, will you choose actions (“ACT”) from the left side or the right side of the handout?

One page to view when poll is up.

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.”

1. Do you think Kareem has low, moderate or high conviction to monitor glucose?
2. On the one-page Big Summary: An Easier Way to Promote Change, will you choose actions (“ACT”) from the left side or the right side of the handout?
3. Read over some of the options under "ACT" on that side of the page to think about how you might address some of these with him in your own words. 

One page to view when poll is up.

• 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 had reviewed her diet and you don’t think diet changes will address her glucose readings. You think she needs insulin.

What can you ask to assess her conviction for starting insulin and yet...

• Acknowledge her current goal and her concerns
• Validate that healthy food choices have many health benefits to her and her family yet...
  • Not alienate 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 mislead her. You want to be transparent that it may help a bit, may not help enough and may not help at all.
• Up-sell insulin by first asking permission to share information and second by relating its use to what she said is important to her 
• 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). 

We never have the time to "word smith" during appointments. After an appointment, take a few minutes to consider what you were pleased with asking, and what you might ask next time and how, now that you know the patient better. You might find it valuable to practice these so they feel more natural to ask during appointmetns. 

Regarding the case of Ava, above, there are thousands of variations with many being shorter. This one below addresses the bullets and might help spark ideas.

• It's clear how important it is for you to be there for your kids. It seems that low energy is making that difficult. 
• You've given this a lot of thought. Your healthy food choices will set a wonderful example for your kids and benefit the health of you and your family in may ways. 
• However, I'm not sure that will bring down your glucose levels enough to help with your energy levels.
• Would you be interested in me decribing how insulin could work very quickly to give you the energy you need - to be with your kids in the way you want? 
• I care about you and what you want for your family. I'm just hoping you have all the pros and cons of starting insulin before you make your decision. I'll certainly respect your answer whatever you decide. Would you be interested in learning more?