"She says she wants to change but she always comes back and nothing is different.
" "Am I doing something wrong? No one seems to take any notice of my advice.
" "I always run out of time.
" "I'm stuck.
" "Some patients just make me feel like I'm rubbish at my job.
" "Why won't he do what he needs to do to care for his health?.
" Have you ever had thoughts like these? You are not alone.
Many clinicians struggle to feel they are good enough.
The section that follows aims to help you think about your patients' actions from a different perspective and introduces some strategies to help you.
Your Patient is Doing What is Right for Him or Her You might not 'get' why your patient is not caring well for his or her health.
People act in accordance with their feelings, beliefs, cultural norms and values, and your belief systems may be very different to your patient's.
Exploring the background to your patient's beliefs can give both of you clarity.
Behaviour that is difficult for you to understand usually stems from a person's belief about its value, or is based in habits that might be difficult to alter.
By asking questions in an open, enquiring way, you will get an insight into the beliefs that are driving the behaviours and actions.
How to Improve Your Relationship with Your Patient Set an Agenda Time in a consultation is short and you will both have an agenda to fulfill.
It is good practice to set the frame of the space.
For example: "We have 15 minutes together today [point towards or indicate the clock].
I will be keeping an eye on the time for us.
Let's prioritize how we are going to spend this time, so we use it wisely.
What would you most like to discuss?" Make a note of the patient's answers.
If the patient starts going off at length, you could say, "Can I pause you for a moment? For now, I just want to get the main areas and then we can focus on each in turn.
To recap, we've got [insert agenda items].
I would like to add one in too, which is [share agenda item].
We may not have time to cover them all today, in which case, I will keep a note and add them to the agenda for next time.
So we can prioritize, which is the most important item to cover today?" Keep track of time.
When you notice you are in the final five minutes, let the patient know.
"We've got five minutes left, so let's make a plan to guide you between now and the next time we meet.
" Help the Patient Become Active Invite the patient to be active within the session.
You could give him or her a sheet of paper and a pen (and a surface to write on).
Do be sensitive if the patient is not keen to write, or his or her literacy levels are low.
Empathy Empathize, empathize, and empathize.
Research into the efficacy of various forms of psychological therapy demonstrates the most important factor in any successful therapy intervention is the relationship.
How are relationships developed? Through shared experience, being listened to, and accepted.
Give permission for your patient to find things difficult.
Focus on the Issue the Patient is Concerned About Often the patient will be most concerned about something completely unrelated to diabetes: financial worries, a sick relative, or a relationship breakdown.
You do not have to be an expert in this or have a solution to it; simply acknowledging it and helping the person identify how to gain his or her own solution, or move forward, can be very helpful.
Be Curious About Successes Be curious about any movement at all in a positive direction.
Ask your patient, "What is going well with your diabetes?" (If patient replies, "nothing," you can always let him or her know that coming to the appointment is a positive step!) "What was different on these days? What helped and what got in the way?" Keep the Goals Very Small Goals need to be small, in fact, the smaller the better.
Success builds on success.
Yes, your patient may need to lose three stone in weight.
But being thoughtful about how to cut out the biscuit with the cup of tea is an important step towards an overall goal (the extra 100 or more calories, a few times a day, over a year, really adds up!).
Do encourage and praise your patient, and notice times when he or she may be quick to discount success.
Bring it out into the open and congratulate your patient for these with a simple, "Well done.
" Be ready to encourage and praise.
Normalize Let your patient know that he or she is not unusual.
Tell your patient you have worked with lots of other people who have struggled with similar issues.
Reassure your patient that his or her experience is "normal.
" Problem-Solve in the Context of Everyday Life Behaviour change can be theory-driven, but it also needs to fit into everyday life.
Think flexibly about how a goal might be implemented and the unspoken barriers that are really preventing change from being realized.
Ask your patient, "What might get in the way of implementing this change?" Problem-solve with your patient.
For example: Does your patient forget to test his or her blood glucose? Could your patient move the kit somewhere it will be seen often, such as by the phone or on the kitchen counter? Will your patient need to ask his or her partner to take on childcare responsibilities to allow some room for exercising a few times a week? When and how will your patient do this? Look out for systemic issues that are obstacles to behaviour change.
In the example above, is the real problem your patient does not have the skills to ask his or her partner for support? In that case, a valuable conversation could be had about how to equip the your patient with the communication skills needed to convey to his or her partner the importance of giving support.
As diabetes is woven so intricately into a person's life, personal goals that are not obviously about a patient's condition are still valid.
They are likely also to have implications for health at some stage.
Be Comfortable with Being Silent In "real" life, we usually have to feel comfortable with individuals before we can be comfortable with being silent with them.
A healthcare appointment is not real life; of course, it is based in reality but it is not subject to the same customs as everyday interactions.
Healthcare professionals can feel a pressure to fill the gaps, to provide more information, to squeeze much into a short period.
Avoid this.
The diabetes consultation may be the one time the patient actually thinks about their diabetes and silence can be an important part of cognitive processing.
If you struggle with silence, count backwards in your head or think of the words of a song to help you.
If the silence goes on for so long, you think it is because your patient doesn't know where to start, simply reflecting this can be beneficial: "It's difficult to know where to start," or "It's hard to know what to say.
" Finish with Next Steps Many patients report struggling to recall the advice provided to them in consultations.
Counter this by recapping what you have spoken about and the strategies you have suggested.
Invite the patient to write these down to aid his or her memory.
What is my personal goal from today? What will I do to achieve this goal? Weekly review: How am I doing towards goal achievement? Go Easy on Yourself: You are Not Responsible As a healthcare professional, you will want to do the best for your patients.
However, you are not their parent, and it is not your job to "solve" their health problems.
They are adults and they are ultimately responsible for their health decisions.
You are in a partnership, and for a partnership to work, collaboration is crucial.
I'd love to help you think more about how to foster empowering and collaborative relationships with your patients.
Do get in touch to find out more at Positive Diabetes.