Often education and training will explicitly focus on developing knowledge and skills. Good educators will include other things in their training. For example, an activity that helps to build confidence in a behaviour, but these might not be explicit or specific. You can follow a p attern for developing training that explicitly focuses on exploring and developing opportunity and motivation, in addition to capability.
Taking each IBO in turn, you can:
1. Establish what the learners already know/already do
2. Explore what might be difficult for the learners to put the specific IBO in practice
3. Develop capability, opportunity and motivation around that IBO through interactive activities in training.
We’ve all likely been on hundreds of training courses. If you think back to the ones where you learned the most, or really stuck with you, were these perhaps the ones where you were more actively involved? There is plenty of evidence that active learning techniques help us process new learning more deeply. Sometimes educators are worried about using active or playful learning because they worry learners will think these ‘childish’ or it will be awkward if an activity ‘lands flat’. We have found that, after an initial surprise that the learning is not all instructional, health professionals in higher- middle- and lower-income countries accept (and often enjoy!) the interactive way of learning. One of the most important active learning techniques is practice and rehearsal. Psychology research tells us that if we want to be able to put something new in practice even when it’s difficult, like back in our busy work setting, we should ‘over-rehearse’ in training, so that it becomes automatic. Rather than the dreaded term ‘role play’, we’d recommend calling activities ‘practice tasks’ and using people’s real experiences or real case studies where possible. Take each IBO in turn and go through the following process.
Design an activity that will establish what learners already know (knowledge) and already can do (skills). It is important to remember that what someone can do is not the same as what someone will do, which is influenced by other factors. This could be as simple as a quiz (consider that some people may not be comfortable sharing scores) or a self-assessed checklist where people are encouraged to identify their learning needs. But first you might want to demonstrate and play with this idea by drawing a bike on a large flipchart or an appropriate example for the country you are working in. Many people KNOW HOW to ride a bike but not everyone CAN ride the bike. By using an example that is not related to work, people feel less worried about sharing their scores and it can help to lead to discussions about work related skills and knowledge.
After an exercise where learners have self-identified their learning needs, collate the scores to avoid any person feeling vulnerable about being exposed as someone who knows less, then note the differences between what learners know and can do and the IBO. You consider sharing the with the learners, as it is often useful for learners and you to have the same understanding about their knowledge and skills in order to prepare the learners to develop necessary knowledge and skills.
Design activities that will develop necessary knowledge. These are the typical activities included in education and training e.g., lectures, workshops etc. When doing this:
Design activities that will develop necessary skills. When doing this follow the pattern:
Design an activity in which learners will reflect on what would get in the way of them doing that IBO in practice (defining barriers) thinking specifically about time, equipment, other people.
Ask the group if they have any solutions for these issues. Share these solutions and discuss them. Then move the group to creating coping plans.
Coping plans are if-then statements where you specify what you will do if a particular barrier arises. For example, if a group identify that prescribing the indicated antibiotic for a particular condition is difficult because they don’t have access to the national prescribing guidelines on their ward, they might identify that carrying the guidelines with them as they go on their ward round might be a solution. Their if-then statement might then be:
“If I am beginning a ward round, then I will pick up the national prescribing guidelines from the office and keep it with me as I see patients.”
Action plans and coping plans are discussed in the ‘Having behaviour change conversations’ module.
Because the views of others may influence whether and how someone does things, it is important to ask learners to reflect on this and share solutions about how to address any barriers. You could start this by asking learners what other people would think of them doing the IBO in practice. You might like to do this by creating a story in which someone similar to the learner did the IBO and asking them to think about what the other team members, patients, families etc. might be thinking in the story. Identify any social opportunity barriers at this point and reflect them back to the learners.
Ask the learners to make coping plans about what they would do if anyone expressed those opinions. They could also make action plans about what they might be able to do to prepare others for them using the IBOs in practice, for example explaining to others in advance and discussing reasons for the IBO.
In our research we have found that experienced professionals in the same field can play a vital role here in sharing how they have negotiated tricky situations (e.g. “I decided to go to the ward lead and say ‘we must do better for our patients, I need to have locks on these cupboard doors to keep our antibiotics secure”).
Three issues seem to affect reflective motivation about IBOs: outcome expectancies, self-efficacy and behavioural attitudes. There may be others specific to your IBOs and there might be literature or anecdotes about these, but these three seem to cover many of the issues raised in many situations.
In order to be motivated to do the IBO, learners need to believe that if they do it, there will be a better outcome for someone. Ensure that you articulate what these better end points are, in other words explain who will benefit from the IBO and how and why. Studies show that communication containing both statistics and individual stories can help people understand why something is beneficial and to whom; and that the story should be told, or be about, someone who is credible: often a leader or someone like the learners themselves. Create some stories, slides, handouts etc. about the positive endpoints of each IBO.
You might also consider asking the learners what they think might improve if they do this IBO and to create their own stories.
Learners might not believe that they can do the IBO – we call this having low self-efficacy about the behaviour. If you don’t think you can do something, you’re unlikely to put much effort into it! Ensure that you build self-efficacy as you go along.
This can be done in a session by using feedback about how others have built their confidence. You could use phrases like ‘other people have found this hard before, but they found that they were able to do this after practicing’.
Consider including a story of people, similar to the group of people you are training, who believed they could not do the IBO but then learnt and now are doing it in practice. Again, it can be a good idea to ask your learners if they can remember a time when they didn’’t think they could do something but then were able to do so. Ask them what helped them and how they felt when they succeeded.
Attitudes about actually doing the new behaviour (not just about the end points) will also influence reflective motivation. Design an activity in which learners discuss what it would be like to do the IBO in practice (or what it is like if they have done it before) and ask them to think about whether there is anything they can do to make it easier or more acceptable. Sometimes asking people to brainstorm ideas together in small groups can help them to come up with some useful solutions.
Prompts and cues are really powerful drivers of behaviour. We tend to think we are in control and making decisions about what we do but actually a lot of our behaviour is automatic and done with little conscious effort. Design an activity in which the learners can think about whether there is anything they can put in their place of work which will prompt or cue them to do the IBO. This might be a poster, or it might be moving where equipment is kept.
Making if-then plans can also support automatic motivation but this time instead of coping with something that might get in the way, you can encourage them to use if-then plans to make a plan that prompts a specific behaviour if they see a particular cue in the environment.
For example, if you wanted someone to follow the 5-moments of hand hygiene, you might get them to make an if-then plan which was something like:
“If I approach a patient’s bed, then I will take the hand gel from my pocket and sanitise my hands”.
This could be in the form of a verbal plan made in small groups or even by making a written pledge as part of becoming an antibiotic guardian https://antibioticguardian.com/
On a final note, if you know what the influences are on the specific behaviours you are trying to change, you can plan the specific interventions (that can include training) that theoretically change those influences. As a group exercise, this is really useful, as it brings partners together to focus on the multiple influences on each key behaviour. You can even do this in a totally participatory way by holding a session in which the people whose practice you are seeking to change are involved in the planning. We find that people are often more receptive to change that they have some control over than change that is imposed.