Confessions of a reformed dietitian
Why the need for change?
The traditional approach for dealing with patients requiring weight management is a direct, advice giving approach. Patients are advised on what changes to make to lose weight, making the assumption they simply lack the knowledge of what they should be doing. If the patient has not lost weight they may be disappointed with their progress and the practitioner is disappointed that they have not followed the advice given. The patient may indeed have achieved small changes in their lifestyle, but they have not been given the opportunity to discuss these. They may even underestimate the importance of these small changes themselves whilst overwhelmed with the disappointment of not losing weight. There is less emphasis in this traditional approach on the process of change, and trying to identify what the patient wants to accomplish, where, how and with whom.
Lifestyle behaviours such as inactivity, overeating, and smoking are deeply embedded into our social, cultural and environmental circumstances. It is important as healthcare practitioners to have the knowledge, skills and understanding of the strategies that facilitate change in patients in these circumstances. Taking a more behavioural approach involves a more directive, client centred counselling style for eliciting behaviour change by helping clients to explore and resolve ambivalence. 1
What does all this mean for everyday practice?
Let me introduce myself. My name is Maria, a Counterweight specialist working with the Counterweight Project Team. I trained as a dietitian nearly 20 years ago to use the traditional advice giving approach. Before joining the Counterweight Project Team I worked in the NHS. I would tailor any dietary advice to referred patients dependent on their diagnosis, offloading them with a list of changes that they needed to make to better manage their condition. I saw lots of patients; indeed I was doing clinics most days. How effective was I? The answer is I don’t know. I know from statistics kept that I was seeing a lot of patients, and was very busy. However there were no audits ever done of effectiveness. The patients either did not return, or they kept on coming for years!
I attended a course introducing the concept of behaviour change, and the use of these techniques in everyday practice. Training time and money in the NHS was, and still is, very limited and I fought hard to be able to attend the course. I’m glad I did as research today has shown that therapist behaviours have been shown to influence treatment outcomes, and that confrontation may have a deleterious impact on self efficacy whereas an empathetic style will support and build self efficacy in patients.2 I realised that I too needed to go through the process of changing my own behaviour as a practitioner to enable me to adopt these new techniques in practice, to facilitate change in my patients.
As a caring profession we are trained to help, to solve patients' problems. Ironically this can impede our ability to listen, as we are busy looking for how we can help when the patient is speaking. There is a tendency to outline all the health risks associated with the patient’s obesity in an effort to get them to change. Non concordant patients may appear to be in denial or resistant to change. This clinical resistance is often a product of the interaction with a practitioner who uses a more confrontational style.3 Assumptions that I made previously were that the patient ought to change for their own good, and indeed, because they were in attendance, wanted to change for their health’s sake. If patients had made no changes and had lost no weight when they next came to clinic, I considered this a failure both on their part and for me personally as a dietitian. The behavioural change course showed me that rather than try to convince patients to change; it would be more effective to elicit an argument for change from the patient themselves. In my novice attempts to try to elicit these change arguments from patients, I learned far more from these same patients I had been seeing for years.
The Skills
This new behavioural approach involved the use of 3 core conditions: - empathy, non judgemental and being genuine. Empathy requires the practitioner to try to understand their patient’s circumstances and points of view. Despite the patient being responsible for their own actions, we as practitioners should try to understand the reasoning behind the choices they are making. It is important that we don’t judge patients for these choices; viewing the patient as a person in their own right, and not a consequence of their actions. There is evidence to suggest that obese patients are discriminated in interactions with health professionals.4 The third condition is being genuine: not being false in words or actions. That traffic warden slapping a ticket on your car is not being empathetic and listening to your story, may be judging you for your illegal parking, and they definitely don’t mean it when they say “have a nice day”. This example is not unique and you may be familiar with many scenarios in both your professional and personal life of poor communications and not being listened to. This will not lead to the patient feeling empowered and ready to make lifestyle changes. I am embarrassed to say I am guilty and it has happened in my clinics in the past; in which I have not been truly listening, may have been judgemental at the lack of patient progress, and far from genuine when I am saying “it’s OK”.
The 3 core conditions can be demonstrated to the patient through the use of active listening. Active listening is the most effective form of communication possible. I learned that for complete listening, it is important to observe your own non verbal behaviour as well as understanding the verbal content of what we are saying .5 The way something is said is just as important as the actual words spoken. Giving the patient your full attention can be expressed by leaning forward, nodding and maintaining comfortable eye contact. It is good to encourage your patient with words and sounds such as; uh huh, yes, go on. Be careful with the use of the word “OK”. One of my personal favourites, until a patient angrily retorted back to me “its not OK, it’s far from OK.” It is hard to break these little habits that we have, but it’s important to think how it may come across to patients.
Searching for facts and trying to problem-solve can impede our listening and understanding of the overall message the patient wishes to convey. This was a difficult concept for me to accept as I had been trained in the NHS to help patients solve their problems. I learned that listening is not easy and requires enormous discipline and self control. l am still learning these listening techniques and it is not second nature yet, but when I am alert, and using the skills to the utmost in a new patient, it really does make a difference.
We have all been trained in our jobs through respective nursing and dietetic courses, and competencies increased through continuous professional development courses in our specialist areas. However, many of these courses provide us with knowledge but not with an improved self awareness as to how we as individuals may be affecting our patients. This self awareness is an important aspect to behaviour change, and is learned through courses in this area. These courses often involve roleplay with an observer present to provide feedback. The word roleplay does not provide me with much glee, but it has provided me with a lot of invaluable feedback as to how my approach and manner may influence patients.
Behavioural change is a process of continual improvement. It does not come all at once. It is a process of learning to use the techniques, and reviewing their effects on patient behaviour. It is important in this respect to partake in some kind of support system. Counterweight offers a programme of mentoring for nurses to increase their confidence and competency in the delivery of the weight management programme to patients. This mentoring provides a valuable opportunity for practitioners to view and learn some of these behavioural techniques with the opportunity for constructive feedback.
Limitations
Time is the major barrier to the use of this behavioural counselling style with patients. There is no denying it does take longer, however there is a plethora of evidence now as to its effectiveness. The use of weight management programmes inclusive of behavioural change techniques is a recommendation from the National Institute of Clinical Excellence (2006) 6 and SIGN (2010). 7 It is worth questioning the time spent with patients currently using traditional advice giving methods and the current effectiveness, as opposed to a more behavioural approach to a smaller number of patients.
Perhaps you have an experience of using a more behavioural approach with your patients that you would like to share, or if you would like to express an interest in further information or training in this area please contact maria.dow@counterweight.org
1. DiLillo V, Siegfried N, Smith West D. Incorporating Motivational Interviewing into behavioural obesity management. Cognitive and Behavioural Practice. 2003; 10: 120-130.
2. Emmons K, Rollnick S. Motivational interviewing in health care settings. Opportunities and Limitations. Am J Prev Med 2001; 20(1) 68-74.
3. Miller W, Sovereign G, Krege B. Motivational interviewing with problem drinkers: II. The drinkers check up as a preventative intervention. Behav Psychother 1988; 16:251-68
4. Foster GD et al (2203). Primary care physicians attitudes about obesity and its treatment. Obesity Research 11(10): 1333-37.
5. Egan G 1994. The skilled helper (5 ed). California: Brookes/Cole
6. National Institute for Health and Clinical Excellence. Technical Guidance for Manfacturers and sponsers on making a submission to a technology appraisal. London: NICE 2004.
7. SIGN. Management of obesity No 115 (.pdf file, accessed Dec 2010)