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Behavior change is the goal of an educational technique called Brief Negotiation taught to staff at Kaiser Permanente medical facilities throughout Northern California. It is a way of educating patients that takes into account whether the patient is able or willing to comply with a treatment regimen. Rather than simply giving patients knowledge, staff make sure patients are willing to put the information into action.
"We try to include the patient in the decision-making process in terms of whatever lifestyle changes they are willing to work on. Instead of lecturing them on how things should go, teaching sessions are really focused on creating an environment of rapport and support," says Robyn Hoban, MA, adult primary care training project manager for Regional Health Education at Kaiser Permanente Northern California in Oakland.
A health care worker doesn’t approach a patient with a set educational agenda, but negotiates with the patient on the information to be discussed. A provider’s interaction with a patient would match the patient’s readiness to learn.
Educators who learn the Brief Negotiation technique begin a teaching session by introducing themselves. Also, they let the patient know how much time they have available to teach and ask permission to talk about a topic, such as the patient’s smoking habit. The patient’s response shapes how the education session continues. The educator assesses where the patient is in terms of changing that particular health behavior before proceeding with the discussion.
"The technique is really using strategic open-ended questions where you get the patient to tell you information as opposed to just answering yes and no questions," explains Hoban. The educator uses an empathetic, nonjudgmental style of interviewing so the patient doesn’t put up walls of resistance. During the discussion, the educator also summarizes what the patient said so the patient knows he or she is being heard correctly.
A scale is used to determine a patient’s readiness to change a behavior. For example, in the case of a smoker, the educator might ask the patient to choose a number between 0 and 10, with 0 being not ready to quit and 10 being ready to throw the pack of cigarettes in the garbage immediately. If the patient is somewhere in the middle of the scale, the health care professional might help the patient explore reasons why he or she doesn’t want to quit smoking yet.
The health care professional needs to be ready to give an advice statement at the end of the conversation. For example, if the patient doesn’t want to quit smoking, the professional would explain briefly that it is bad for the patient’s health and make sure the patient has resources to turn to when he or she is ready to quit.
Because there are things the patient needs to know, the nurse or whoever is teaching makes the pertinent information part of the dialogue, whether in the advice statement or conversation. The goal is to tailor the conversation so the patient is receptive to the information, explains Hoban.
The Regional Health Education department at Kaiser provides two-day workshops on the Brief Negotiation technique. The training is open to all members of Kaiser’s adult primary care teams, which include clinical health educators, nurse case managers, physical therapists, pharmacists, and physicians. (For more information on training tailored for physicians, see article on p. 31.)
The first training session is eight hours long and is very interactive. Workshop attendees learn the technique by lecture, discussion, and practice. They are taught how to present information to the patient based on the patient’s readiness to change. For example, staff learn what kinds of questions to ask if the patient is not ready to make any behavior changes.
The two trainers bring scenarios for practice sessions, but they also spend time practicing and troubleshooting real case scenarios brought by participants. The second part of the workshop is scheduled for the following week so participants can practice in real-life situations during their work and bring any problems they had back for discussion.
While the workshop is not mandatory, all care team members are encouraged to go. They are notified of the course offering by e-mail and employee newsletters. (To learn about other programs that teach staff how to teach, see article above.)
Workshop participants receive a packet of information to reinforce the teaching, which includes a Brief Negotiation road map that walks the health care professional through a teaching session. "The tricky part about the model is that there is really no one way to do it. It is really using the skills the best you can in the environment you are in," says Hoban.
For more information on Brief Negotiation, contact:
• Robyn Hoban, MA, Adult Primary Care Training Project Manager, Kaiser Permanente Northern California, Regional Health Education, 1950 Franklin St., Oakland, CA 94612. Telephone: (510) 987-3511. Fax: (510) 873-5379. E-mail: Robyn.Hoban@ncal.kaiperm.org.