Having behaviour change conversations

Having conversations with individuals in which you come to a shared understanding of AMS behaviours and the influences on them is a very important part of the behavioural science of AMS.

In fact, our communication skills come into everything we do to change practice in AMS. Whether you’re leading a training, or speaking at a committee meeting or feeding back the results of an audit, our specific questions, phrases and style can have a huge impact on others around us.

Sometimes, we need to explore the influences on and behaviours of, a large group of people and develop interventions to change those behaviours. But often, we are speaking to a single individual about their practice. It is useful in these situations to gather information about their own capability, opportunity and motivation for practices related to antimicrobial stewardship. There are lots of things that might influence whether a single person behaves in a way that supports stewardship. They might not know what they should be doing differently, they might know but not agree with the new way of working. They might agree and for some reason never seem to get round to it. Finding out how an individual person thinks and feels will help you to have a meaningful conversation about change.

Using open questions

During training or other kinds of conversations, it can be useful to use open questions – questions that can’t be answered with a ‘yes’ or ‘no’ or with a one-word response, because we are trying to get the person to do most of the talking and thinking. We want the person to have a conversation with us that is open, curious and participatory, bringing out their own ideas for change. So for instance ‘what do you think we could do in this situation?’ rather than ‘this is what you should do in this situation’. This is of course especially important where we are not familiar with the environment or culture of a new place.

If you think back to conversations that you have enjoyed, these are often where people have asked you questions and listened to your opinions. Generally, open questions lead to better, more satisfying and more useful conversations. If this is new to you, you can practise talking to people in a closed or open way and reflect on the time taken, effort of the interviewer and interviewee and general satisfaction with the conversation.

Providing the right information when it’s asked for

Motivational interviewing communication style suggests we provide information when it’s asked for, in chunks, and checking back to see what people make of it. They suggest to provide information using:

Elicit – Ask them what they already know about the topic, ask what they’d like to know, and/or ask their permission to provide information

Provide – 1 tailored chunk of information, perhaps with ‘others in your situation have found X useful’, or ‘in our setting, we tend to …’

Elicit – Ask ‘what do you make of that?’ to guide your conversation further and give you a guide on whether more details or other bits of information are needed.

These behaviour change communication activities are based on the MAP competencies developed by Profs Marie Johnston and Diane Dixon for NES in Scotland. Health_behaviour_change_competency_framework.pdf

Practising conversations

Behaviour change conversations can be difficult so you might want to practise. In the vignettes handout, there are some typical scenarios that people might experience when thinking about practice change related to AMS. You can use these scenarios to do some practise.

Noticing positive change and progress

Our brains are wired to notice problems, threats and dangers – if we were not so good at this, our cave man ancestors would never have survived to pass on their genes to us today! Our governance systems in healthcare are set up the same way – to check for problems, moving from one problem to another to rectify issues and ensure quality and safety. However, this means we don’t always have the time and headspace to notice positive change and progress in a positive direction – our own and other people’s. It can be useful to add ‘what’s going well’ to team meetings in AMR projects, and taking time to notice and remark on progress towards the team’s AMR goals in a genuine, empowering way (‘we got that report in to the chief medical officer, what a huge and determined effort from everyone, thank you for your commitment to this project’).

Using behaviour change techniques

Research findings suggest that conversations are more likely to be effective in changing behaviour if they include certain techniques that we call ‘behaviour change techniques’. There are almost 100 different techniques, the ones we are suggesting here are the ones that have good evidence for their simplicity to use and their effectiveness in supporting behaviour change.

Reflective motivation conversations

Focusing on the pros of changing or not changing

You can ask people to talk about the pros of changing practice and the pros of not changing practice. Remember that communication is better and more effective if the person thinks of their own reasons, but you can prompt them to think about different things too. In this situation, you need to be neutral, helping the person weigh up their own pros and cons rather than ‘jumping on’ one side or another. There is some evidence that, for some behaviours, pulling out the cons for NOT changing can increase the salience of the changes. MI recommends that questions like ‘what worries you about the way things are now?’ and ‘what difficulties have arisen from the current practices?’ are useful. You can then follow this with ‘what might be the advantages to changing?’

Looking to the future

As part of this, you could ask people to imagine things in a future timeframe e.g. 1 or 5 years if they did or did not change things in their team or hospital setting. This can gently encourage them to generate their own reflective motivation for changing, but be careful to adopt a curious approach there rather than a ‘telling them’ approach.

Automatic motivation conversations

Behaviours are more likely to be sustained if they become the usual or habitual way you do things.

If-then plans

If-then plans are those plans we make where we identify the ‘if’ and we make a plan about what to do in that situation, which is the ‘then’. We can make two types of if-then plans: an action plan (what you are going to do in a specific situation) and a coping plan (anticipating barriers and planning what to do if they happen). You can ask people to make two plans, an action plan and a coping plan. But first, ask them to prioritise what the first thing they might need to do to start to change and focus on that.

Monitoring and adapting

Self-monitoring is about noticing and recording your behaviours. Adapting the environment is about looking at where you work and changing things around you to support you doing the behaviour. These are both interventions to support automatic motivation and generate habits.

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