You are about to hear a series of interactive role-plays designed for VHA healthcare providers to practice using MI and TEACH to help their veteran patients engage in positive behavior change.
Kevin Robinson is a 52-year-old Army veteran, who works in construction. He is obese and was diagnosed with Type 2 diabetes and high blood pressure four years ago. At his last appointment, he had an A1C of 9.5. Kevin knows he needs to do more to manage his weight and diabetes, but other concerns keep getting in the way. You will hear four different versions of Kevin’s appointment with Nurse Practitioner Bell the last two conversations are advanced versions where Nurse Practitioner Bell will be using more advanced MI techniques.
Nurse Practitioner Bell’s goals for this conversation are to:
Notice when Nurse Practitioner Bell is successfully working towards the conversation goals and when she struggles. You will also hear feedback from the coach who will give you a sense of what Nurse Practitioner Bell is doing well and where she can make improvements.
Nurse Practitioner Bell: Hi Kevin, it's nice to see you again.
Kevin: Good to see you too, Susan!
Nurse Practitioner Bell: How are you feeling today, Kevin?
Coach: Great! Nurse Practitioner Bell asked an open-ended question to check in with Kevin and see how he is feeling before discussing an agenda for today's visit.
Kevin: Eh, little curious what my numbers are at, I suppose. Other than that, I mean, I guess there's this one thing...
Nurse Practitioner Bell: What would you like to focus on during today's visit?
Coach: Nurse Practitioner Bell invited Kevin to share his agenda. In response, he shared a lot of what he's going through.
Kevin: Thanks for asking. Was waiting for the "workout more", "eat that less" routine. But if we get to chat about what I want...
Kevin: I've just been feeling worn out lately. Zonked, you know? Particularly when I get home from work.Hard to even concentrate on the whole weight thing right now.I might not have been perfect with the exercise and eating, but I didn't miss one day of meds...
Nurse Practitioner Bell: It's great to hear that you've been taking your medication regularly, Kevin!... I'm also hearing that you'd like to work on a plan to have more energy.
Kevin: Yeah. Be nice to have a little more gas in the tank.
Coach: Good! Nurse Practitioner Bell affirmed Kevin's efforts to take his medication regularly and acknowledged his concern about his lack of energy
Nurse Practitioner Bell: To reduce the tiredness it might be helpful to understand it a bit more.Where do you think the tiredness is coming from?
Kevin: Well... from the meds... right?
Nurse Practitioner Bell: It could be from your medications, that's true. It could be compounded by a few other sources, too.I could share some more info on this, if you'd like?
Kevin: Had a feeling maybe it wasn't gonna be as simple as I hoped. Share away.
Nurse Practitioner Bell: The medication you take helps control your diabetes and blood pressure,and blood pressure medication can sometimes make you feel more tired.Or it could be your weight itself that's contributing to the tiredness.Good news is, either way, if we work on a plan that helps you manage your weight, that could reduce your tiredness,and potentially reduce the amount of medicine you need to take.
Kevin: Sounds... promising. But what kind of plan, exactly?
Nurse Practitioner Bell: We'd start by looking at your A1C levels and blood pressure.Then we could put our heads together and think of some other ways to manage those levels- besides just medication. How would you feel about that?
Kevin: Doesn't sound too bad... so far.
Coach: Nurse Practitioner Bell did a good job of using the Elicit-Provide-Elicit technique! Because she first asked Kevin what he thought might be causing his tiredness, he was more open to hearing the information Nurse Practitioner Bell provided.
Coach: Weight management is important, though it's better to let the topic arise naturally from Kevin's own experiences. When Nurse Practitioner Bell lectures Kevin, he may become defensive.
Coach: Good! Nurse Practitioner Bell assured Kevin that she did not intend to reprimand him. As a result, Nurse Practitioner Bell recovered the conversation and gained an opportunity to share important information.
Nurse Practitioner Bell: No problem, Kevin. According to your chart, your A1C level is 9.
Kevin: Well -- OK. Whoa. Gotta digest that for a sec. Man, I was really hoping I made more of a dent there.
Nurse Practitioner Bell: What does an A1C level of 9 mean to you?
Kevin: I know it means my sugar's are running high...
Nurse Practitioner Bell: That's true - but they are moving in the right direction.
Kevin: Yeah *sigh* I just.. I thought they would be be lower than that by now.
Coach: Good! Nurse Practitioner Bell checked Kevin's understanding of his A1C level before continuing the conversation.
Nurse Practitioner Bell: What led you to think your sugars would be lower?
Kevin: I mean, I was taking my meds, I did do a little exercise and dieting, I didn't think it needed that much effort.It's just been taking so long... I need to get them down... on the sooner side...
Coach: Good! Nurse Practitioner Bell asked a question to better understand Kevin's perspective and found out some important information about how he has been approaching his health.
Nurse Practitioner Bell: You'd like control over your weight, and your A1C levels to improve... sooner rather than later.
Coach: Good! Nurse Practitioner Bell used a reflection to acknowledge and amplify Kevin's reasons for change.
Kevin: It's just... I went to my son's game the other day...Seein' those kids tearin' up the field... reminded me of... well, me... back when I could run like that.When I was on active duty, I would do PT at the crack of dawn, work all day,and play a game of pickup football before dinner without even breaking a sweat.
Coach: Kevin shared some information that could lead him to positive change. Nurse Practitioner Bell can explore this topic to build his motivation!
Nurse Practitioner Bell: You thought back to when you were younger, full of energy. You wish you could... turn back the clock a little.
Kevin: Well, it's not just that, exactly... It's just... back in the day...
Coach: Good! By reflecting Kevin's statement about his former fitness levels, Nurse Practitioner Bell elicited Kevin's desire, reasons, and need for change.
Kevin: I was the freakin' high school quarterback, for cryin' out loud. Watching my son's game it.. brought back memories.Like of MY father - when I was a kid, he would throw the ball to me every afternoon. Made me love the game.These days, I'm winded just after a few throws. Makes it kinda hard to throw it to MY kids...
Kevin: Man, I really thought I would have made more progress on my weight by now.I did try to lose a few pounds, before I was feeling so tired. Guess it wasn't enough.But... the thought of doing more? It's just so overwhelming!
Nurse Practitioner Bell: I know losing weight isn't the easiest thing - which is why it's so great to hear you gave it a try, Kevin!
Kevin: Well, thanks! It did feel good when I stepped on the scale and saw the number lower once in a while......Certainly felt a whole lot better than when it went back up again...
Coach: Nice! By empathizing with Kevin and affirming his efforts, Nurse Practitioner Bell made him feel listened to and respected. As a result, Kevin was encouraged to use change talk and share his experience.
Nurse Practitioner Bell: What were you doing in particular that helped you lose weight... helped that scale move in the direction you wanted?
Coach: Great! Nurse Practitioner Bell used an open-ended question to learn more about Kevin's experience with weight loss strategies.
Kevin: I tried a little exercise, eating a little better. It was going okay... to begin with.Then I just kinda ran outta steam... Really thought it'd be easier to keep up with...
Nurse Practitioner Bell: I hear you... it can be hard to keep up the momentum!Tell me more about the exercise and diet plan, and maybe we can figure out how you might get back on track.
Kevin: Well, I tried a couple stints on the treadmill, cooked at home a couple nights a week.Didn't mind either actually - just found I didn't really have time to fit it all in.
Coach: Good! Nurse Practitioner Bell acknowledged the challenges of keeping up an exercise routine while prompting Kevin to share his past experience. As a result, Kevin felt listened to and respected.
Nurse Practitioner Bell: I hear you. Managing time is a tough one. Maybe you can fit more activity in while you are at work?
Kevin: At work? I... don't think that's realistic.
Coach: Though Nurse Practitioner Bell empathized with Kevin about the difficulties of time management, she also suggested a solution for him. Instead, affirm and explore his past attempts at weight management to help him find his own solutions.
Kevin: Problem is...
Kevin: I get home from work late every night. Then on the weekend,all my time goes to getting life in order before the next week starts!
Nurse Practitioner Bell: So you're wondering how to fit losing weight into your busy schedule.If you could, you're willing to consider some options.
Kevin: Yeah!
Nurse Practitioner Bell: I can definitely help with that!
Kevin: That'd be great!
Coach: Nurse Practitioner Bell did a great job using an action reflection that reframed Kevin's concerns as problems he can solve.
Nurse Practitioner Bell: So I can help, but before we start, would it be OK if I tried to summarize what you've told me so far,including the issue with time, just to make sure I've got this right?
Kevin: Sure.
Nurse Practitioner Bell: From our conversation so far, I'm hearing time's a particular concern for you...
Coach: Good! Nurse Practitioner Bell used a summary to show Kevin that she has heard his concerns and priorities before moving on.
Nurse Practitioner Bell: You arrive home late from work and you just don't have time for anything else.
Nurse Practitioner Bell: On the other hand, you'd like to make some changes in your life to lose some weight and reduce your A1C level so you can be less tired.
Kevin: Yes, exactly.
Nurse Practitioner Bell: And...
Nurse Practitioner Bell: Your dad was a role model of health to you. And you're wanting to be that for your kids.
Coach: Because Nurse Practitioner Bell’s summary included Kevin's previously mentioned reason for staying healthy, Kevin felt understood and he was prompted to reflect more. This led to change talk!
Kevin: Yeah, bingo. That's it.
Kevin: My son... he looks up to me, you know? He hears these stories about his quarterback hero Dad,he sees the shiny trophies in the house - he asks me to throw the ball around with him...and then here's me struggling to get out of the armchair... Some role model I am...
Kevin: Time to make a change, I guess.
Nurse Practitioner Bell: Great to hear you're considering making a change!Would it be OK if we explored how important making a change to achieve this goal is to you?To do this, we use something called an Importance Ruler. On a scale between zero and ten,where ten is extremely important and zero not at all important,how important is it to you to work on your weight?
Coach: Great! Nurse Practitioner Bell used the Importance Scale to ask Kevin about his perception of the importance of weight management. This will create opportunities to evoke change talk and build motivation.
Kevin: Hmm... I'd say at least... eight... out of ten...
Nurse Practitioner Bell: What makes you say that number as opposed to a lower one?
Kevin: Well...
Kevin: I'd sure love to be able to throw the ball to my kids like my own father did with me.
Nurse Practitioner Bell: So we talked a bit about how you might make some changes in diet and exercise.Would it be ok if we talked about some weight loss programs that may work for you?
Kevin: I... maybe. I guess I'm still a little concerned with the time it will take to actually engage in the program. But whaddya got?
Coach: Though Nurse Practitioner Bell supported Kevin's autonomy by asking permission, a better way to gauge Kevin's readiness would've been to use the Importance Scale.
Nurse Practitioner Bell: So - you'd consider ways to lose weight as long as they're manageable, accomplishable, and use your time efficiently.
Kevin: Well, yeah. That sure would be nice. ...got anything in mind?
Coach: Good! Nurse Practitioner Bell used an action reflection that included some of Kevin's change talk and also moved the session towards planning a change.
Nurse Practitioner Bell: So there were some particular challenges you had with having enough time to be active...
Kevin: Yeah...
Kevin: ... I'm getting home too late from work to do anything active.
Nurse Practitioner Bell: What are some ways you could overcome these time-related challenges?
Coach: Nurse Practitioner Bell’s open-ended question prompted Kevin to find strategies to address his time barriers! Since these ideas came from him, he is more likely to commit to change.
Kevin: I guess I could ask my boss if I could come in a little earlier, leave a little earlier -he's let a few other folks do that recently...
Nurse Practitioner Bell: Any time you're able to devote to being active will pay off in better health!
Nurse Practitioner Bell: What is your familiarity with how the MOVE! program can help manage your weight?
Coach: Nurse Practitioner Bell does a good job of asking Kevin what he already knows about the MOVE! program before sharing information with him.
Kevin: Uh, I don't know much about it. I know it's some weight loss group for vets, right?
Nurse Practitioner Bell: Yes, MOVE! is the VA's weight management program. It was developed specifically for veterans -and it has actually worked for veterans. It focuses on health and wellness;mainly through diet, physical activity and behavior change.But the big thing is it's customizable... meaning it can be tailored to your own goals and preferences. How does that sound to you?
Kevin: Look, I'm all for losing weight, but like I mentioned before, one of my biggest problems right now is time.Which any kind of "program" sounds like it's going to take a lot of.
Nurse Practitioner Bell: Time is an issue for many veterans.Would it be OK if I shared some aspects of MOVE! that might help you with your concern about time?
Kevin: Sure.
Coach: Great! Because Nurse Practitioner Bell started with a reflection and asked for permission to share info about the MOVE! program, Kevin was receptive to what she had to say.
Nurse Practitioner Bell: You can even use a mobile app to access MOVE! content that you supplement with calls or texts!
Kevin: An app?! Now that's useful... especially if it's anything like my banking one...I must have saved myself days reviewing info on my own and talking to my rep remotely.
Nurse Practitioner Bell: You also have the option of setting up a 1:1 call with a clinician, rather than having to go and see someone in person.
Kevin: Hmmm... that does save me on commuting time...
Nurse Practitioner Bell: There are evening sessions, so you wouldn't have to take any time out of work.
Kevin: Well, I can't take any time out of work, so that's pretty much a must-have.... still, glad to hear that's the case!
Nurse Practitioner Bell: Do any of these features sound like the program could be helpful?
Kevin: Hmmm... maybe... maybe. They definitely sound like time-savers...
Nurse Practitioner Bell: That's great, Kevin - perhaps I can share how losing weight and keeping it off can help you lower those A1C levels and reach your goals?
Kevin: Now that's something I would love to hear.
Coach: Great! Nurse Practitioner Bell asked for permission before sharing information. As a result, Kevin is more receptive to hearing what she had to say.
Nurse Practitioner Bell: Losing just 5% of your body weight can help get those A1C levels lowered.So at 256 pounds, we're looking at... around 13 pounds. You'd be less tired, and...
Nurse Practitioner Bell: ...have more energy to play with your kids!
Nurse Practitioner Bell: How does that sound?
Nurse Practitioner Bell: Sounds like you're willing to consider working on your weight,especially if you can participate in a way that addresses your preferences and needs.
Kevin: Yeah, that sounds about right.
Nurse Practitioner Bell: We can work on a plan that'll help you with your weight management -AND caters to your preferences - by using "SMART goals".Would it be OK if I explained what a SMART goal is and maybe we set one together?
Kevin: Sure.
Nurse Practitioner Bell: Each letter of "SMART" stands for something about the goal.Specific, measurable, action-oriented, realistic, and time-based.
Kevin: Well, I like the realistic part...
Nurse Practitioner Bell: OK, well, what's something you think might be realistic then?
Coach: Good! Nurse Practitioner Bell asked Kevin for permission to share information, which respects Kevin's autonomy and encourages collaboration. In addition, she took the time to explain SMART goals to help Kevin succeed in making a change.
Kevin: Uh... maybe... just... talking with a MOVE! person in the next week or two?
Nurse Practitioner Bell: Great!
Nurse Practitioner Bell: So, Kevin, what would work best for you, given your time limitations, for connecting with a MOVE! Clinician?
Kevin: Could they give me a call on my cell...and leave me a number to call back if I can't pick it up?
Nurse Practitioner Bell: Yes....they can call you. Is there a particular time of day that works best for you?
Kevin: After 5? I'm usually off work by then.
Nurse Practitioner Bell: I'll pass that on the the MOVE! team. Now that's a specific plan!
Coach: Good! Nurse Practitioner Bell collaborated with Kevin by asking for Kevin's preferences for scheduling a call with the MOVE! clinician.
Nurse Practitioner Bell: Now on a scale of zero to 10,how confident are you that you will meet the goal of a follow-up with a MOVE! clinician to explore options?With zero being not at all confident and 10 being extremely confident?
Coach: Great. Using a Confidence Scale to assess his ability to achieve his goal helps both Nurse Practitioner Bell and Kevin identify and address any barriers that might be in the way.
Kevin: Hmm, I'd say about a... eight?
Nurse Practitioner Bell: What led you to say 8, and not a lower number, like 5?
Kevin: Well, to start off with, it's just starting a conversation - can't be that hard -
Kevin: And I can make time to be more active by...
Kevin: ...going to work earlier and coming home earlier, so I've got more time in the evening to do a little exercise.
Kevin: It's worth it to lose some weight. Feel less tired. Especially if losing weight means...
Kevin: ...I'll have more energy to play with my kids.
Kevin: If that's the case then sign me up!
Nurse Practitioner Bell: Nice work. Well, I guess we're all done here.
Kevin: Thanks for your time. I appreciate it. I'll remember what we talked about here today.
Nurse Practitioner Bell: That's great to hear Kevin. I'll put in a consult to MOVE! and have them give you a call.
Kevin: Thanks!
Nurse Practitioner Bell: No problem! See you in three months at our next appointment!
Kevin: See you then!
Coach: Kevin decided to work on his weight, and set a goal to connect with a clinician from the MOVE! program to identify options that fit with his schedule. Three months later at his next visit, Kevin reports that he has had MOVE! telephone counseling sessions and he is eating better and getting regular exercise a few times a week. He has lost about 5% of his weight so far - about 15 pounds and he's motivated to lose more!
Nurse Practitioner Bell: Hi Kevin, it's nice to see you again.
Kevin: Good to see you too, Susan!
Nurse Practitioner Bell: I had a look at your chart before you arrived. Your weight is around the same as your last visit... 256 pounds.
Coach: Nurse Practitioner Bell did a good job mentioning Kevin's medical chart, though it may be better to check in first before analyzing information.
Kevin: *sigh* Hoping it might've been a little lower. I guess I could be exercising more and eating better - but... I dunno. I'm just a little preoccupied right now.
Nurse Practitioner Bell: You really need to make exercise and healthy eating a priority.
Kevin: Yeah, yeah, tell me something I don't know.
Coach: By trying to tell Kevin what his priorities should be, Nurse Practitioner Bell missed opportunities to learn about his struggles and his desire to change. Instead, she can try to elicit priorities from him with an open-ended question.
Kevin: Like why I'm so tired all the time....
Kevin: I've just been feeling worn out lately. Zonked, you know? Particularly when I get home from work.Hard to even concentrate on the whole weight thing right now.I might not have been perfect with the exercise and eating, but I didn't miss one day of meds...
Nurse Practitioner Bell: I understand you want to talk about tiredness, but we should really stick to weight right now.
Kevin: I understand YOU want to talk about weight, but I'd really prefer to talk about getting rid of the tiredness first.
Coach: Kevin was already uncomfortable talking about weight. The more Nurse Practitioner Bell pressed the issue, the more defensive he became.
Nurse Practitioner Bell: For the sake of your health, let's concentrate on weight management and your blood pressure.
Kevin: Look, no offense - but I only come to these sessions because my wife makes me.And right now you're not telling me anything I don't know and I kinda feel like you're not listening to anything I say.
Coach: By trying to persuade Kevin, Nurse Practitioner Bell missed opportunities to explore what he wants and feels.
Nurse Practitioner Bell: The meds help reduce blood pressure. To address tiredness, we might focus on other factors.
Kevin: Like what kind of 'other factors'?
Coach: Even though Nurse Practitioner Bell is offering Kevin an opportunity to think about the impact of his behavior on his fatigue, it is best to avoid statements that discount the patient's efforts.
Nurse Practitioner Bell: Weight management can help with the tiredness.
Kevin: OK... how exactly?
Nurse Practitioner Bell: The medication you take helps control your diabetes and blood pressure,and blood pressure medication can sometimes make you feel more tired.Or it could be your weight itself that's contributing to the tiredness.Good news is, either way, if we work on a plan that helps you manage your weight, that could reduce your tiredness,and potentially reduce the amount of medicine you need to take.
Kevin: Sounds... promising. But what kind of plan, exactly?
Nurse Practitioner Bell: We'd start by looking at your A1C levels and blood pressure.Then we could put our heads together and think of some other ways to manage those levels- besides just medication. How would you feel about that?
Kevin: Doesn't sound too bad... so far.
Coach: Nurse Practitioner Bell did a good job of using the Elicit-Provide-Elicit technique! Because she first asked Kevin what he thought might be causing his tiredness, he was more open to hearing the information she provided.
Nurse Practitioner Bell: No problem, Kevin. According to your chart, your A1C level is 9.
Kevin: Well -- OK. Whoa. Gotta digest that for a sec. Man, I was really hoping I made more of a dent there.
Nurse Practitioner Bell: We really need to get those levels down, Kevin. They need to be closer to 7 - for the good of your own health.Yeah, yeah.
Coach: Reprimanding Kevin led him to feel less willing to open up. Instead, Nurse Practitioner Bell can consider exploring his understanding about A1C levels, which may provide opportunities to offer information and build motivation.
Nurse Practitioner Bell: You've got some work to do to get to your stated goal of 7.
Kevin: Man... was hoping I made more progress than that. And now I feel like a big fat failure.
Coach: Though this response reflects a desire to improve Kevin's diabetes management, it was experienced as judgmental and discouraging. Instead, Nurse Practitioner Bell can consider exploring what Kevin understands about A1C levels and self-management.
Nurse Practitioner Bell: Don't worry, there's plenty of time to get those A1C levels lowered.
Kevin: That's easy for you to say! You don't have to worry about...
Coach: Even though Nurse Practitioner Bell intended to comfort Kevin, it is usually more effective to explore a patient’s understanding and motivation for participating in treatment and self-management.
Kevin: I've just been a bit more worried about my current weight situation.... My uncle Jim, he... he was a big guy too.Could "eat whatever he wanted, whenever he wanted"...and still lift a beer keg over his head without breaking a sweat.Then when he was a year older than I am now he had a heart attack and dropped dead. Left Aunt Cathy all by herself...
Coach: Kevin shared some information that could lead him to positive change. Nurse Practitioner Bell can explore this topic to build his motivation!
Nurse Practitioner Bell: Eating healthier could make a real impact on your weight.
Kevin: You make it sound like it's the flip of a switch.If it was so easy do you think there'd be so many guys my size out there? My own wife goes easier on me than you do.
Coach: Giving Kevin advice led him to respond with sustain talk. Next time, Nurse Practitioner Bell can use a reflection to give Kevin the opportunity to explore his own motivations.
Kevin: My wife... she's a saint. When I came back from overseas, she always had my back.Helped me get back on my feet, look for a job, read just to civilian life -all on the heels of raising two kids practically by herself.I'm not putting her through what Uncle Jim put his wife through...
Kevin: Man, I really thought I would have made more progress on my weight by now.I did try to lose a few pounds, before I was feeling so tired. Guess it wasn't enough.But... the thought of doing more? It's just so overwhelming!
Nurse Practitioner Bell: Come on, you can do it! A couple visits to the gym will help you shed some pounds.
Kevin: Um... have you seen me? I'm a... big guy. It is DEFINITELY not easy for a person of my size to lose weight.
Coach: Telling Kevin that losing weight is easy led him to feel like Nurse Practitioner Bell was downplaying his struggles.
Nurse Practitioner Bell: You should try the MOVE! program.
Kevin: Hmm, I think I've heard of that. I'm... not sure I'm ready to talk about a "program" yet.
Coach: Kevin is not yet ready to talk about the MOVE! program. Instead of making a suggestion, it would be more effective to explore his perspective and/or respond to him in a way that makes him feel listened to and respected.
Nurse Practitioner Bell: Everyone can lose weight, no matter their size.
Kevin: Yeah, right. I've heard that before. Look...
Coach: Though Nurse Practitioner Bell was trying to be encouraging, this kind of encouragement can discount Kevin's feelings and experience.
Kevin: I tried a little exercise, eating a little better. It was going okay... to begin with.Then I just kinda ran outta steam... Really thought it'd be easier to keep up with...
Nurse Practitioner Bell: Kevin, when you run out of steam, just have those health benefits in mind and keep trying.
Kevin: Try HARDER? I don't think you realize how hard this already is!
Nurse Practitioner Bell: I do get it Kevin... it is hard!I am just saying it is useful to think about all the benefits of losing weight when you hit roadblocks.
Kevin: That's easy to say... but it is doesn't HELP me with the roadblocks!
Coach: Nurse Practitioner Bell’s encouragement came off as dismissive of Kevin's efforts and challenges. Instead, she can explore what strategies worked for him in the past.
Nurse Practitioner Bell: Kevin, I can provide info on some weight management programs that could help you.
Kevin: Eh, that's all right Ms Bell, I don't think I really need more info.It's really just time that's my biggest concern right now.
Coach: Before sharing information about programs, it's better to give Kevin the opportunity to talk about his past experience with weight management options.
Nurse Practitioner Bell: Kevin, I really think you should hear what I have to say about these weight-loss programs.
Kevin: And I'm telling you I don't have the time.
Coach: Until Kevin has his concerns about time acknowledged, he is uninterested in hearing about weight loss programs.
Kevin: Problem is...
Kevin: When I come home, all I wanna do is have a chance to relax for a sec - you know,kick my feet up, lie down on the couch. I don't really wanna do anything strenuous.
Nurse Practitioner Bell: I can tell you a few ways you can manage your time better.
Kevin: Yeah, OK. Well, you're the expert. I guess...
Coach: Instead of offering advice, Nurse Practitioner Bell can consider engaging and collaborating with Kevin by exploring his ideas for freeing up time.
Nurse Practitioner Bell: Now let's talk about how important making a change is to you to overcome these challenges.
Kevin: Really? O....kay...
Coach: Though exploring importance is a great way to look at motivation, it would be better for Nurse Practitioner Bell to reflect and summarize what she has learned so far before moving on.
Nurse Practitioner Bell: So we talked a bit about how you might make some changes in diet and exercise.Would it be ok if we talked about some weight loss programs that may work for you?
Kevin: I... maybe. I guess I'm still a little concerned with the time it will take to actually engage in the program. But whaddya got?
Coach: Though Nurse Practitioner Bell supported Kevin's autonomy by asking permission, a better way to gauge Kevin's readiness would've been to use the Importance Scale.
Nurse Practitioner Bell: You should join the MOVE! program. Do you know what that is?
Coach: Rather than telling Kevin that he "should" join the MOVE! program, which is directive and has a judgmental tone, Nurse Practitioner Bell can try to avoid the use of "shoulds" and instead ask Kevin about his understanding and interest in a weight management program.
Kevin: Uh, I don't know much about it. I know it's some weight loss group for vets, right?
Nurse Practitioner Bell: Yes, MOVE! is the VA's weight management program. It was developed specifically for veterans -and it has actually worked for veterans. It focuses on health and wellness;mainly through diet, physical activity and behavior change.But the big thing is it's customizable... meaning it can be tailored to your own goals and preferences. How does that sound to you?
Kevin: Look, I'm all for losing weight, but like I mentioned before, one of my biggest problems right now is time.Which any kind of "program" sounds like it's going to take a lot of.
Nurse Practitioner Bell: It's very important for your health that you participate in some sort of weight loss program.I'm sure you'll be able to figure out how to fit it in your schedule.
Kevin: I'm sorry. This... this program's just not for me. I'm sorry but... I think I'm done for today. Maybe next time we can figure out something else.
Coach: Kevin felt Nurse Practitioner Bell was pushing him to do something he is not ready to do, so he pushed back and ended the conversation.
Nurse Practitioner Bell: The MOVE! program will help you lower your weight while using your time efficiently.
Coach: While the MOVE! program can help with weight and time management, it'd be more effective to first ask for permission to share information.
Kevin: I'm glad you are so confident. Mind explaining a little how?
Nurse Practitioner Bell: For example...
Nurse Practitioner Bell: You can even use a mobile app to access MOVE! content that you supplement with calls or texts!
Kevin: An app?! Now that's useful... especially if it's anything like my banking one...I must have saved myself days reviewing info on my own and talking to my rep remotely.
Nurse Practitioner Bell: There are evening sessions, so you wouldn't have to take any time out of work.
Kevin: Well, I can't take any time out of work, so that's pretty much a must-have.... still, glad to hear that's the case!
Nurse Practitioner Bell: Do any of these features sound like the program could be helpful?
Kevin: Hmmm... maybe... maybe. They definitely sound like time-savers...
Nurse Practitioner Bell: Sounds like you're already on board with making a plan to link up with the MOVE! program?
Kevin: Well.. not sure if I'd say "complete" one yet... but maybe "try"? You did bring up some interesting points...
Coach: It would be more efficient and effective to respectfully explore Kevin's understanding and motivation before trying to push ahead with the MOVE! program. Asking about desire, ability, reasons, and need might even evoke change talk and build Kevin's motivation.
Nurse Practitioner Bell: Losing weight can help lower your A1C levels.
Kevin: I mean, I figured, but... how much weight exactly?
Coach: It is true that losing weight can help reduce A1C levels, though it may be better for Nurse Practitioner Bell to ask Kevin for permission before sharing this information.
Nurse Practitioner Bell: Losing just 5% of your body weight can help get those A1C levels lowered.So at 256 pounds, we're looking at... around 13 pounds. You'd be less tired, and...
Nurse Practitioner Bell: ...be there for your wife!
Nurse Practitioner Bell: How does that sound?
Nurse Practitioner Bell: Let's work on setting a goal together.
Kevin: OK.
Coach: Though Nurse Practitioner Bell’s choice to set a goal is valuable, she missed an opportunity to collaborate with Kevin on setting a SMART goal, one that is behaviorally Specific, Measurable, Action-oriented, Realistic and has a Timetable to complete.
Nurse Practitioner Bell: Is there a goal in mind you'd like to achieve?
Kevin: Uh... talking with someone from MOVE!... at, uh, some point?
Nurse Practitioner Bell: Sounds good to me!
Kevin: All right. Goal set. Easy.
Nurse Practitioner Bell: Nice work. Well, I guess we're all done here.
Kevin: Thanks for your time. I appreciate it. I'll remember what we talked about here today.
Nurse Practitioner Bell: That's great to hear Kevin. I'll put in a consult to MOVE! and have them give you a call.
Kevin: Thanks!
Nurse Practitioner Bell: No problem! See you in three months at our next appointment!
Kevin: See you then!
Coach: Though Kevin says he's interested in the MOVE! Program, he never ends up connecting with a MOVE! Clinician. When Nurse Practitioner Bell eventually sees Kevin again, he has gained weight since his last visit.
Nurse Practitioner Bell: Hi Kevin, it's nice to see you again.
Kevin: Ms. Bell.
Nurse Practitioner Bell: Please, call me Susan.
Nurse Practitioner Bell: How are you feeling today, Kevin?
Coach: Great! Nurse Practitioner Bell asked an open-ended question to check in with Kevin and see how he is feeling before discussing an agenda for today's visit.
Kevin: Eh. Wondering how your chart's got me pegged this time, I guess.Otherwise, well , I got something else on my mind - if you really want to know.
Nurse Practitioner Bell: What would you like to focus on during today's visit?
Coach: Nurse Practitioner Bell invited Kevin to share his agenda. In response, he shared a lot of what he's going through.
Kevin: Well, THANK you for asking. I'll tell you what I wanna talk about, all right. Taking less meds.
Kevin: I've been feeling exhausted since you upped my dose last session -barely have enough energy to make it through the day, let alone amp up the exercise.I wasn't happy taking extra meds in the first place,and now I'm worried what other side effects there'll be if I keep taking more of this freakin' stuff.
Nurse Practitioner Bell: OK. I'm hearing you have a number of concerns here - you're tired,you believe the extra medication is causing it, and you're worried about other side effects.
Kevin: Exactly.
Nurse Practitioner Bell: I understand. I want to help you address the exhaustion, and explore all the factors involved.Is there an area you'd like to concentrate on first?
Kevin: Eh, not really. It's up to you.
Coach: Kevin is experiencing some conflict about this topic.
Nurse Practitioner Bell: Talk to me about the tiredness.
Kevin: What's to talk about? Before, I felt less tired. Now, I feel more tired. I liked before.
Nurse Practitioner Bell: You're worried because you have less energy than usual, and you're concerned it may be from the meds.
Kevin: Yeah. It sucks! I can't afford to take a sick day 'cause I'm feelin'... sluggish.
Nurse Practitioner Bell: Of course. I'll look for any issues when I check your labs.
Coach: Good! Nurse Practitioner Bell’s reflection about Kevin's concerns let him know she is listening.
Nurse Practitioner Bell: What else do you think might be contributing to the tiredness?
Coach: Great! Nurse Practitioner Bell’s question explored Kevin's understanding of what could be causing his tiredness and evoked change talk.
Kevin: Else? Hmm. I know having diabetes can make you tired when your blood sugar is high. And...
Kevin: Well, I know this extra weight I'm walking around with sure isn't helping.
Nurse Practitioner Bell: Exactly! Having better control over your diabetes can help.Another source of the tiredness could be from the weight itself.Managing the weight could help reduce your feelings of tiredness.
Kevin: Heavy. Literally!
Kevin: Hmm. Guess there's some work to do first before lowering the meds... But I'm just not there yet...
Nurse Practitioner Bell: Wanting to reduce your current meds dosage is understandable, and definitely something we can work on together...
Kevin: I'm very glad to hear that. What's the next step?
Coach: Good! By legitimizing Kevin's concerns and offering to address them, Nurse Practitioner Bell is deepening her partnership with him.
Nurse Practitioner Bell: So, you'd feel better if you had other ways to manage your blood pressure and diabetes,besides taking additional medication.
Kevin: Right. These extra meds are a real pain in the... well, they're a real pain.
Nurse Practitioner Bell: What do you know about ways to improve control of your blood pressure and diabetes, without taking extra meds?
Coach: Good! Using an open-ended question is a key skill that allows Nurse Practitioner Bell to gauge what Kevin :knows about the impact and benefits of weight loss, as well as any misconceptions.
Kevin: I mean... I guess I know if I could lose a few pounds, it'd help with my whole... situation.
Nurse Practitioner Bell: Exactly! Losing weight would help you manage both your diabetes and high blood pressure......and would likely reduce your need for medication.
Kevin: Yeah, *sigh*. Weight's not my favorite subject. But if it means less medication...
Kevin: You're certainly giving me something to think about...
Nurse Practitioner Bell: You'd like to reduce your meds because you're worried about future side effects of the medication and how they make you feel...
Kevin: You got that right. Popping these pills already makes me feel tired - who knows what's next!I don't want to wake up tomorrow as a freakin'... zombie... or something!
Nurse Practitioner Bell: Well, , I don't think turning into a zombie has been reported as a side effect.Though I can share with you another way we can address your concern about taking more medication, if that's OK?
Kevin: Sure. Whatcha got.
Coach: Addressing Kevin's concern and also asking his permission to share information enhanced Nurse Practitioner Bell’s connection and partnership with Kevin.
Nurse Practitioner Bell: The medication is helping to control your blood pressure.Although you could try a different blood pressure medication that might produce less tiredness,I hear your concerns about other side effects. So, another option is to help you get your weight down,which would help us control your blood pressure and allow us to use less medicine.
Coach: Great! Nurse Practitioner Bell linked Kevin's concerns to the benefits of weight loss, allowing her to discuss both topics in a different way.
Kevin: Yeah, good point.
Kevin: OK, OK, I get it.
Nurse Practitioner Bell: So, sounds like you're willing to consider other ways to reduce your need for medication.
Kevin: Yeah, I mean, guess I can't let the tiredness stop me from doing something about the tiredness.Kinda a vicious cycle. We could talk about doing something about it, I suppose. How would we start?
Nurse Practitioner Bell: Wonderful! Well, to kick things off, we could chat about your current A1C levels or YOUR weight.Would one of these options work for you?
Kevin: Hmm... well I'm not sure I'm totally ready to talk weight just yet.How about we start with the A1C levels to see where I'm at, and then go from there?
Nurse Practitioner Bell: No problem, Kevin. According to your chart, your A1C level is 9.
Kevin: Well -- OK. Whoa. Gotta digest that for a sec. Man, I was really hoping I made more of a dent there.
Nurse Practitioner Bell: What does an A1C level of 9 mean to you?
Kevin: I know it means my sugar's are running high...
Nurse Practitioner Bell: That's true - but they are moving in the right direction.
Kevin: Yeah *sigh* I just.. I thought they would be be lower than that by now.
Coach: Good! Nurse Practitioner Bell checked Kevin's understanding of his A1C level before continuing the conversation.
Nurse Practitioner Bell: What led you to think your sugars would be lower?
Kevin: I mean, I was taking my meds, I did do a little exercise and dieting, I didn't think it needed that much effort.It's just been taking so long... I need to get them down... on the sooner side...
Coach: Good! Nurse Practitioner Bell asked a question to better understand Kevin's perspective and found out some important information about how he has been approaching his health.
Nurse Practitioner Bell: You'd like control over your weight, and your A1C levels to improve... sooner rather than later.
Coach: Good! Nurse Practitioner Bell used a reflection to acknowledge and amplify Kevin's reasons for change.
Kevin: I mean, in general I'm OK with the fact that a paragon of health I'm not.'Course I can't be TOO out of shape..gotta be able to keep up with work and all.Never thought I'd spend the rest of my life in construction after I came back from overseas.But it's managed to pay our bills for thirty odd years... so far.
Coach: Kevin shared some information that could lead him to positive change. Nurse Practitioner Bell can explore this topic to build his motivation!
Nurse Practitioner Bell: You want to make sure you're healthy enough to keep your job so you can continue to provide for your family.
Kevin: Yeah. Besides what I make, we don't have anything else coming in. And we have a lotta payments that need to go out..
Coach: Good! By reflecting Kevin's statement about how his weight might affect his job performance and income, Nurse Practitioner Bell elicited his desire, reasons, and need for change.
Kevin: These days my job's got me managing more and building less -but there's still enough work involved that it ain't a walk in the park.If the boss swings by and there aren't enough guys on the project,I gotta show I can carry my own... my family relies on it.
Kevin: Man, I really thought I would have made more progress on my weight by now.I did try to lose a few pounds, before I was feeling so tired. Guess it wasn't enough.But... the thought of doing more? It's just so overwhelming!
Nurse Practitioner Bell: I know losing weight isn't the easiest thing - which is why it's so great to hear you gave it a try, Kevin!
Kevin: Well, thanks! It did feel good when I stepped on the scale and saw the number lower once in a while......Certainly felt a whole lot better than when it went back up again...
Coach: Nice! By empathizing with Kevin and affirming his efforts, Nurse Practitioner Bell made him feel listened to and respected. As a result, Kevin was encouraged to use change talk and share his experience.
Nurse Practitioner Bell: What were you doing in particular that helped you lose weight... helped that scale move in the direction you wanted?
Coach: Great! Nurse Practitioner Bell used an open-ended question to learn more about Kevin's experience with weight loss strategies.
Kevin: I tried exercising more, and eating better. But NOTHING seemed to stick.Didn't realize how hard it would be. It's just so frustrating...
Coach: Nurse Practitioner Bell can explore Kevin's past experience with weight management before moving forward in the conversation.
Nurse Practitioner Bell: So you did start exercising... glad to hear that!
Kevin: Yeah, I did. And, I mean, I'd like to make some more strides in that direction... so to speak.
Nurse Practitioner Bell: That's great - so tell me more about what happened.
Kevin: Well, I tried... yoga... if you can believe that. My daughter made me do it. But... it was JUST AWFUL.They had me bending my limbs in no places limbs should be bending. I was hurting for days.
Coach: Great! Even though Kevin is frustrated about his earlier exercise plan, Nurse Practitioner Bell affirmed his past efforts and encouraged him to share more about his experience.
Nurse Practitioner Bell: Sounds like your daughter supports you doing physical activity, and it's great you gave yoga a try.You've found though it's not your thing. What's an exercise that's worked for you in the past?
Kevin: I mean, in the Army, I liked running... Already got the shoes. AND the treadmill.Thing is, it's hard for me these days - just don't have enough minutes in the day, you know?
Nurse Practitioner Bell: So, on the one hand, time is an issue for you.On the other hand, you enjoy running and you have shoes and a treadmill... right there at home!
Kevin: Right, exactly.
Coach: Nurse Practitioner Bell did a great job using a double-sided reflection. She reflected Kevin's concern and also ended with a reflection of his change talk, which tends to produce more change talk!
Kevin: Man. Losing weight sure could be easier, but nice to hear there's... options.
Nurse Practitioner Bell: How did you get started with healthy meals?
Kevin: Well, my wife and I... she's... got a lot to love too, you know? What I mean is, she's... OVERWEIGHT... like me. So we thought we'd try to lose a little weight together
Kevin: But... it didn't really work out.
Coach: Good! Nurse Practitioner Bell’s open-ended question opened an opportunity to build on his previous knowledge and experience.
Nurse Practitioner Bell: Good to hear you and your wife are interested in working on your weight. People are more successful losing weight when their family supports their efforts! I understand it may have been a challenge... what exactly happened?
Kevin: Well, she went to, you know, the HEALTHY grocery store. Came home with... lots of green stuff.And, well... doesn't help that she cooks worse than I clean. And I clean by throwing dishes in the sink and praying.Aaaand... you can imagine how that went. We gave up home-cooked meals pretty fast.
Coach: Good! Nurse Practitioner Bell reflected Kevin's challenges with eating healthy and asked an open-ended question. This prompted him to share more about his experience.
Nurse Practitioner Bell: Kevin, that's great you and your wife decided to lose weight together by choosing a specific goal - cooking healthy meals.At the same time, I understand that some food is... tastier than others.Any ideas how... to have meals that are healthy AND tasty?
Coach: Great! Nurse Practitioner Bell affirmed Kevin's past effort to cook healthier food with his wife. She also prompted him to share how he could help select healthier food items.
Kevin: I mean, I could tag along at the grocery store - if we went on the weekends.If only to put different kinds of food in the grocery cart.
Nurse Practitioner Bell: That way, you'd be able to select more kinds of foods you like. And then how about in the kitchen?
Kevin: Well, I'm happy to be her "sous chef" - if she lets me.Plenty of experience chopping vegetables during my deployment.Just need to carve out some extra time so I can help out with the prep.
Nurse Practitioner Bell: Lots of great ideas here Kevin - sounds like you have some skill in the kitchen!
Kevin: Maybe this whole weight loss thing is not as hopeless as I thought...
Nurse Practitioner Bell: Sounds like you've had some challenges... many people have similar ones.What are your thoughts about trying again, perhaps with help to address the challenges?
Kevin: Yeah, I guess I could try... If I could just open up a couple extra hours in my schedule...
Kevin: Problem is...
Kevin: My evening hours are kinda sacred.When else am I gonna watch my games and keep up with my teams? I can't sacrifice that!
Nurse Practitioner Bell: So you're wondering how to fit losing weight into your busy schedule.If you could, you're willing to consider some options.
Kevin: Yeah!
Nurse Practitioner Bell: I can definitely help with that!
Kevin: That'd be great!
Coach: Nurse Practitioner Bell did a great job using an action reflection that reframed Kevin's concerns as problems he can solve.
Nurse Practitioner Bell: So I can help, but before we start, would it be OK if I tried to summarize what you've told me so far,including the issue with time, just to make sure I've got this right?
Kevin: Sure.
Nurse Practitioner Bell: From our conversation so far, I'm hearing time's a particular concern for you...
Coach: Good! Nurse Practitioner Bell used a summary to show Kevin that she has heard his concerns and priorities before moving on.
Nurse Practitioner Bell: You have time in the evening, but use that for watching your favorite sports teams.
Nurse Practitioner Bell: On the other hand, you'd like to make some changes in your life to lose some weight and reduce your A1C level so you can be less tired.
Kevin: Yes, exactly.
Nurse Practitioner Bell: And...
Nurse Practitioner Bell: Your job provides your main source of financial security- you need to stay healthy to make sure you can support your family.
Kevin: Yeah, bingo. That's it.
Kevin: My job isn't as taxing as it used to be, but if I can't do the basic stuff when the need arises,I'm gone. I can't let that happen...
Kevin: Time to make a change, I guess.
Nurse Practitioner Bell: Great to hear you're considering making a change!Would it be OK if we explored how important making a change to achieve this goal is to you?To do this, we use something called an Importance Ruler. On a scale between zero and ten,where ten is extremely important and zero not at all important,how important is it to you to work on your weight?
Coach: Great! Nurse Practitioner Bell used the Importance Scale to ask Kevin about his perception of the importance of weight management. This will create opportunities to evoke change talk and build motivation.
Kevin: I'd say at least... six... out of ten...
Nurse Practitioner Bell: What makes you say that number as opposed to a lower one?
Kevin: Well...
Kevin: I need to make sure I'm able keep my job and provide for my family.
Nurse Practitioner Bell: So we talked a bit about how you might make some changes in diet and exercise.Would it be ok if we talked about some weight loss programs that may work for you?
Kevin: I... maybe. I guess I'm still a little concerned with the time it will take to actually engage in the program. But whaddya got?
Coach: Though Nurse Practitioner Bell supported Kevin's autonomy by asking permission, a better way to gauge Kevin's readiness would've been to use the Importance Scale.
Nurse Practitioner Bell: So - you'd consider ways to lose weight as long as they're manageable, accomplishable, and use your time efficiently.
Kevin: Well, yeah. That sure would be nice. ...got anything in mind?
Coach: Good! Nurse Practitioner Bell used an action reflection that included some of Kevin's change talk and also moved the session towards planning a change.
Nurse Practitioner Bell: So there were some particular challenges you had with having enough time to be active...
Kevin: Yeah...
Kevin: ... I gotta get my sports in, somehow.
Nurse Practitioner Bell: What are some ways you could overcome these time-related challenges?
Coach: Nurse Practitioner Bell’s open-ended question prompted Kevin to find strategies to address his time barriers! Since these ideas came from him, he is more likely to commit to change.
Kevin: I guess I could DVR the games during the week...then I'd have some time to play a little sports, throw the baseball around or something.
Nurse Practitioner Bell: Any time you're able to devote to being active will pay off in better health!
Nurse Practitioner Bell: What is your familiarity with how the MOVE! program can help manage your weight?
Coach: Nurse Practitioner Bell did a good job asking Kevin what he already knows about the MOVE! program before sharing information with him.
Kevin: MOVE!? MOVE!?!
Nurse Practitioner Bell: It's the VA's weight management progra--Oh, I know what MOVE! is, all right! I've TRIED the MOVE! program before. It... didn't end well.
Nurse Practitioner Bell: What happened?
Kevin: I didn't like the group sessions, I hated the crappy food they suggested,and I ended up quitting almost as soon as I started.
Coach: Kevin had a bad experience with the MOVE! Program. Consider exploring his experience to learn whether there are ways his concerns about participating can be addressed.
Nurse Practitioner Bell: Sounds like you gave it a try. Tell me a little more about your reactions to the group sessions.
Kevin: I sat in on a couple of 'em. Buncha guys talking about their problems.
Coach: Great! By asking an open-ended question Nurse Practitioner Bell learned more about his experience, which may help you and Kevin identify ways to address his concerns.
Nurse Practitioner Bell: What is your understanding of what else happens in group sessions?
Kevin: Lectures on how I should eat better?
Nurse Practitioner Bell: Not exactly - could I share some core elements of the program?
Kevin: Yeah, sure.
Nurse Practitioner Bell: They offer knowledge and strategies to help folks incorporate dietary, physical activity and other changes into their busy lives.There is some lecturing, though also lots of opportunity to interact.
Kevin: That's all well and good but... you know, I just don't really like talking about my... problems... in groups.
Nurse Practitioner Bell: Sounds like it was uncomfortable for you to participate in a group session.Would it be OK if I shared some information about other ways to participate in MOVE! other than group sessions?
Kevin: Like what?
Nurse Practitioner Bell: The MOVE! program has other options. In fact, there are one-on-one in person sessions, telephone sessions, even an app!
Kevin: An app huh? Now an app I could probably get behind. I do love my other ones.And if I can use the app to get some help managing my weight without a group session, even better.
Nurse Practitioner Bell: Nice to hear, Kevin!
Coach: Good! Because Nurse Practitioner Bell acknowledged Kevin's concerns with a reflection and paired this with asking permission to share information about MOVE! options, Kevin felt like you were collaborating and addressing his preferences, rather than trying to persuade him.
Kevin: Hmmmm. I still got some issues with the MOVE! program, but you got me thinking.Maybe if we could talk through my other concerns...
Nurse Practitioner Bell: You weren't satisfied with the dietary information you received.
Kevin: It was NOT helpful! They emphasized... salads..., you know, rabbit food!I just couldn't see myself eating that stuff. Do I look like a rabbit to you?
Coach: Good! You used a reflection which prompted Kevin to share more about his experience. Though he is unhappy, it opens the door to explore potential remedies.
Nurse Practitioner Bell: No, no, you don't look like a rabbit. You want some diet guidance that caters to your tastes.Right! Things I actually wanna eat! You know, like cheeseburgers!I mean, if I had a diet that included cheeseburgers, I think I could even cut down on how much of them I ate.
Nurse Practitioner Bell: So you recognise how portion control can help you manage your weight.
Kevin: Well yeah - I think I remember them talking about that in the program. I guess I learnt more than I thought...
Coach: By responding with a reflection here, rather than with a suggestion or admonition, Nurse Practitioner Bell came alongside Kevin, which led to an opportunity to offer an affirmation! Kevin:responded with some self-reflection and even some change talk!
Nurse Practitioner Bell: Exactly! So... could I share with you a feature about the MOVE! program?
Kevin: Sure, as long as it doesn't involve KEEN-NOAH... KEEN-whatever-it's-called
Nurse Practitioner Bell: Ok, great. Your MOVE! dietitian can definitely take your dietary preferences into account and create a meal plan that's nutritious and also customized to your tastes. Including ensuring there is no quinoa.
Kevin: Huh. Well if there are other dietary options, then maybe that's something I can consider.
Coach: Good! Kevin feels more open to MOVE! because Nurse Practitioner Bell is making it clear that his needs around food preferences are valid.
Kevin: Perhaps it's worth checking out again after all.
Nurse Practitioner Bell: How did you feel when you left the program early?
Coach: Nurse Practitioner Bell did a good job asking Kevin about his feelings about leaving early. She can continue to acknowledge the challenges from his past experiences to make sure Kevin feels heard.
Kevin: I quit after like two weeks... maybe three. Wasn't a good fit. So why go back again?
Nurse Practitioner Bell: I hear your concern about the program being a good fit .You're wondering how it could be different if you tried again.
Kevin: Exactly.
Nurse Practitioner Bell: It might be helpful thinking about the aspects of the program you didn't like - and those you did!Consider if there's a way to get what you want out of the program.
Kevin: Hmmm.... I guess that's worth having a think about...especially if there's a chance it'll make my experience better next time.
Coach: Great! Nurse Practitioner Bell’s reflection validated Kevin's concerns and reframed what he said. As a result, she encouraged Kevin to reconsider the MOVE! program in a different way.
Kevin: Program's sounding a lot better this time 'round! Maybe I oughta give it another shot.
Nurse Practitioner Bell: So what are your thoughts about MOVE! programs now?
Kevin: I'm feelin' a little better about the whole thing. My last experience with the MOVE! wasn't great,but now I realize there are lots of options that might work for me. I guess I could give it another go.
Nurse Practitioner Bell: That's great, Kevin - perhaps I can share how losing weight and keeping it off can help you lower those A1C levels and reach your goals?
Kevin: Now that's something I would love to hear.
Coach: Great! Nurse Practitioner Bell asked for permission before sharing information. As a result, Kevin is more receptive to hearing what she has to say.
Nurse Practitioner Bell: Losing just 5% of your body weight can help get those A1C levels lowered.So at 256 pounds, we're looking at... around 13 pounds. You'd be less tired, and...
Nurse Practitioner Bell: ... do what you want to be able to do at work!
Nurse Practitioner Bell: How does that sound?
Nurse Practitioner Bell: Sounds like you're willing to consider working on your weight,especially if you can participate in a way that addresses your preferences and needs.
Kevin: Yeah, that sounds about right.
Nurse Practitioner Bell: We can work on a plan that'll help you with your weight management -AND caters to your preferences - by using "SMART goals".Would it be OK if I explained what a SMART goal is and maybe we set one together?
Kevin: Sure.
Nurse Practitioner Bell: Each letter of "SMART" stands for something about the goal.Specific, measurable, action-oriented, realistic, and time-based.
Kevin: Well, I like the realistic part...
Nurse Practitioner Bell: OK, well, what's something you think might be realistic then?
Coach: Good! Nurse Practitioner Bell asked Kevin for permission to share information, which respects Kevin's autonomy and encourages collaboration. In addition, she took the time to explain SMART goals to help Kevin succeed in making a change.
Kevin: Uh... maybe... just... talking with a MOVE! person in the next week or two?
Nurse Practitioner Bell: Great!
Nurse Practitioner Bell: So, Kevin, what would work best for you, given your time limitations, for connecting with a MOVE! Clinician?
Kevin: Could they give me a call on my cell...and leave me a number to call back if I can't pick it up?
Nurse Practitioner Bell: Yes....they can call you. Is there a particular time of day that works best for you?
Kevin: After 5? I'm usually off work by then.
Nurse Practitioner Bell: I'll pass that on the the MOVE! team. Now that's a specific plan!
Coach: Good! Nurse Practitioner Bell collaborated with Kevin by asking for Kevin's preferences for scheduling a call with the MOVE! clinician.
Nurse Practitioner Bell: You seem pretty confident that you'll keep to this goal.
Kevin: Well, you've got me thinking it's worth devoting some effort to.
Coach: Instead of telling Kevin that he seems confident, Nurse Practitioner Bell can consider using a Confidence Scale to explore his ability to achieve his goal and handle any barriers that might be in the way.
Nurse Practitioner Bell: Now on a scale of zero to 10,how confident are you that you will meet the goal of a follow-up with a MOVE! clinician to explore options?With zero being not at all confident and 10 being extremely confident?
Coach: Great. Using a Confidence Scale to assess his ability to achieve his goal helps both Nurse Practitioner Bell and Kevin to identify and address any barriers that might be in the way.
Kevin: Hmm, I'd say about a... eight?
Nurse Practitioner Bell: What led you to say 8, and not a lower number, like 5?
Kevin: Well, to start off with, it's just starting a conversation - can't be that hard -
Kevin: And I can make time to be more active by...
Kevin: ...watching my sports on the weekend, so I can maybe actually play a little sports during the week.
Kevin: It's worth it to lose some weight. Feel less tired. Especially if losing weight means...
Kevin: ...I'll be up for any physical work my job needs me for.
Kevin: If that's the case then sign me up!
Nurse Practitioner Bell: Nice work. Well, I guess we're all done here.
Kevin: Thanks for your time. I appreciate it. I'll remember what we talked about here today.
Nurse Practitioner Bell: That's great to hear Kevin. I'll put in a consult to MOVE! and have them give you a call.
Kevin: Thanks!
Nurse Practitioner Bell: No problem! See you in three months at our next appointment!
Kevin: See you then!
Coach: Kevin decided to work on his weight, and set a goal to connect with a clinician from the MOVE! program to identify options that fit with his schedule. Three months later at his next visit, Kevin reports that he has had MOVE! telephone counseling sessions and he is eating better and getting regular exercise a few times a week.He has lost about 5% of his weight so far - about 15 pounds... and he's motivated to lose more!
Nurse Practitioner Bell: Hi Kevin, it's nice to see you again.
Kevin: Ms. Bell.
Nurse Practitioner Bell: Please, call me Susan.
Nurse Practitioner Bell: I had a look at your chart before you arrived. Your weight is around the same as your last visit... 256 pounds.
Coach: Nurse Practitioner Bell did a good job mentioning Kevin's medical chart, though it may be better to check in first before analyzing information.
Kevin: *sigh* Man, just can't win. And I bet now you're gonna tell me it should it be lower.Look, I've been dealing with some other stuff...
Nurse Practitioner Bell: You really need to make exercise and healthy eating a priority.
Kevin: Yeah, yeah, tell me something I don't know.
Coach: By trying to tell Kevin what his priorities should be, Nurse Practitioner Bell missed opportunities to learn about his struggles and his desire to change. Instead, she can try to elicit priorities from him with an open-ended question.
Kevin: Like why I need to take all these extra meds.
Kevin: I've been feeling exhausted since you upped my dose last session -barely have enough energy to make it through the day, let alone amp up the exercise.I wasn't happy taking extra meds in the first place,and now I'm worried what other side effects there'll be if I keep taking more of this freakin' stuff.
Nurse Practitioner Bell: OK. I'm hearing you have a number of concerns here - you're tired,you believe the extra medication is causing it, and you're worried about other side effects.
Kevin: Exactly.
Nurse Practitioner Bell: I understand. I want to help you address the exhaustion, and explore all the factors involved.Is there an area you'd like to concentrate on first?
Kevin: Eh, not really. It's up to you.
Coach: Kevin is experiencing some conflict about this topic.
Nurse Practitioner Bell: Kevin, I understand you're concerned, but you don't have to worry about additional side effects.
Coach: Dismissing Kevin's concern led him to focus more on lowering the dosage without wanting to investigate any other contributing factors. Nurse Practitioner Bell can use reflections to provide Kevin an opportunity to discuss his worries about side effects.
Kevin: How can you know that for certain?!All I know is we reduce the meds, we reduce the side effects. So where are we with that?
Nurse Practitioner Bell: Kevin, because you're worried about side effects, we should explore how you can manage your weight.
Kevin: Aw, man. Always comes back to the weight, huh.
Nurse Practitioner Bell: If you lower your weight, you'll be less reliant on the medication. And therefore, you'll have less side effects.Ok, I'll get right on that.
Nurse Practitioner Bell: I realise it's not easy - but we have had patients that have put their mind to losing weight and had some success.
Kevin: It is tough. But it's certainly comforting to hear you've had other patients who managed to do it.
Coach: Nurse Practitioner Bell validated Kevin's feeling that weight loss is not easy. There'll be an opportunity for her to explore his experience of attempting weight loss and his other feelings about it.
Kevin: Hmm. Guess there's some work to do first before lowering the meds... But I'm just not there yet...
Nurse Practitioner Bell: The medication might not be the only reason you're feeling so tired---- it's certainly from SOMETHING.
Coach: When Nurse Practitioner Bell shared her opinion, Kevin felt like she was discounting his concerns. She can consider acknowledging Kevin's concerns and/or using an open-ended question to explore what Kevin thinks might be contributing to his tiredness.
Nurse Practitioner Bell: I definitely understand your concern is the tiredness, and we can concentrate on that.But it might not just be the medication that's the culprit...
Coach: Acknowledgement of Kevin's concerns is helpful. However, Nurse Practitioner Bell also presented a counter idea which can seem dismissive. It would be more effective for her to explore Kevin's understanding, using open-ended questions and additional reflections.
Kevin: Hmm... how's that?
Nurse Practitioner Bell: If you are concerned about tiredness, the best way for you to gain energy is if you lose weight.
Coach: Dismissing Kevin's concerns and pushing weight loss as a remedy led Kevin to feel disengaged and dismissed. It would've been more effective to explore Kevin's understanding about the impact of his weight and diabetes on his tiredness by using open-ended questions and reflections.
Kevin: I'm sorry. I'm so tired I feel like I can't concentrate on anything else but getting rid of the tiredness...
Kevin: Look, I know you mean well. But I still just want to focus on lowering my meds.
Nurse Practitioner Bell: Do you think your weight might be the cause of the tiredness, rather than the meds?
Coach: By asking a closed-ended question about weight, Kevin feels like Nurse Practitioner Bell is dismissing his concerns about the medications and pushing the issue of weight. She can consider a reflection that let's him know you hear his concerns.
Kevin: Well, I've been heavy for a while. I've only JUST started taking this medicine. So I'd like it reduced. Stat.
Nurse Practitioner Bell: Well, reducing the medication is one option. Before we make that decision, I'd like to explore other causes of your tiredness, if that's OK with you.
Kevin: Sure, fine. Whatever.
Nurse Practitioner Bell: You know, if you get that weight under control like we talked about last session, you wouldn't have these issues.
Coach: Telling Kevin to get his weight under control led him to shut down. He will see Nurse Practitioner Bell as more of a partner if she asks open-ended questions and try to find out more about his experience with weight management.
Kevin: Coulda, shoulda... didn't.
Kevin: Look, I know you just want me to concentrate on talking about me lowering weight rather than meds,so there's no point going around in circles here.Let's just move on and talk about whatever we're "supposed" to talk about at the start of these sessions...A1C levels or something, right?
Nurse Practitioner Bell: No problem, Kevin. According to your chart, your A1C level is 9.
Kevin: Well -- OK. Whoa. Gotta digest that for a sec. Man, I was really hoping I made more of a dent there.
Nurse Practitioner Bell: We really need to get those levels down, Kevin. They need to be closer to 7 - for the good of your own health.Yeah, yeah.
Coach: Reprimanding Kevin led him to feel less willing to open up. Instead, Nurse Practitioner Bell can consider exploring his understanding about A1C levels, which may provide opportunities to offer information and build motivation.
Nurse Practitioner Bell: You've got some work to do to get to your stated goal of 7.
Kevin: Man... was hoping I made more progress than that. And now I feel like a big fat failure.
Coach: Though this response reflects a desire to improve Kevin's diabetes management, it was experienced as judgmental and discouraging. Instead, consider exploring what Kevin understands about A1C levels and self-management.
Nurse Practitioner Bell: Don't worry, there's plenty of time to get those A1C levels lowered.
Kevin: That's easy for you to say! You don't have to worry about...
Coach: Even though Nurse Practitioner Bell intended to comfort Kevin, it is usually more effective to explore his understanding and motivation for participating in treatment and self-management.
Kevin: I've just been a bit more worried about my current weight situation.... My uncle Jim, he... he was a big guy too.Could "eat whatever he wanted, whenever he wanted"...and still lift a beer keg over his head without breaking a sweat.Then when he was a year older than I am now he had a heart attack and dropped dead. Left Aunt Cathy all by herself...
Coach: Kevin shared some information that could lead him to positive change. Nurse Practitioner Bell can explore this topic to build his motivation!
Nurse Practitioner Bell: Eating healthier could make a real impact on your weight.
Kevin: You make it sound like it's the flip of a switch.If it was so easy do you think there'd be so many guys my size out there? My own wife goes easier on me than you do.
Coach: Giving Kevin advice led him to respond with sustain talk. Next time, can use a reflection to give Kevin the opportunity to explore his own motivations.
Kevin: My wife... she's a saint. When I came back from overseas, she always had my back.Helped me get back on my feet, look for a job, read just to civilian life -all on the heels of raising two kids practically by herself.I'm not putting her through what Uncle Jim put his wife through...
Kevin: Man, I really thought I would have made more progress on my weight by now.I did try to lose a few pounds, before I was feeling so tired. Guess it wasn't enough.But... the thought of doing more? It's just so overwhelming!
Nurse Practitioner Bell: You should try the MOVE! program.
Kevin: The MOVE! program?! Oh man, don't get me started on the MOVE! program!
Coach: Kevin is not yet ready to talk about the MOVE! program. Instead of making a suggestion, it would be more effective to explore his perspective and/or respond to him in a way that makes him feel listened to and respected.
Nurse Practitioner Bell: Come on, you can do it! A couple visits to the gym will help you shed some pounds.
Kevin: Um... have you seen me? I'm a... big guy. It is DEFINITELY not easy for a person of my size to lose weight.
Coach: Telling Kevin that losing weight is easy led him to feel like Nurse Practitioner Bell was downplaying his struggles.
Nurse Practitioner Bell: Everyone can lose weight, no matter their size.
Kevin: Yeah, right. I've heard that before. Look...
Coach: Though Nurse Practitioner Bell is trying to be encouraging, this kind of encouragement can discount Kevin's feelings and experience.
Kevin: I tried exercising more, and eating better. But NOTHING seemed to stick.Didn't realize how hard it would be. It's just so frustrating...
Coach: Nurse Practitioner Bell can explore Kevin's past experience with weight management before moving forward in the conversation.
Nurse Practitioner Bell: Yoga is hard at first for many people... But with perseverance, it's not as tough.
Kevin: Look, I get it. But I'm not those people. Wanna talk 'bout something else?
Coach: By comparing Kevin's exercise experience to others, Nurse Practitioner Bell discredited his earlier effort. Try to explore with him exercises that he may like.
Kevin: I'm starting to wonder if I should even bother...
Nurse Practitioner Bell: I have some healthy eating handouts that you may find worthwhile.
Kevin: And I'm sure the brochures taste as good as they look.
Nurse Practitioner Bell: That's not really what they're meant for...
Kevin: Well, I can think of a few other uses for 'em... but none of them are gonna involve me eating better.Guess healthy food just isn't on the table.
Coach: Offering brochures as a way to address challenges may lead to push back. Before sharing new information, it's useful to explore Kevin's previous efforts so Nurse Practitioner Bell can identify successes as well as Kevin's ideas for overcoming barriers.
Kevin: I really just don't know about this.
Nurse Practitioner Bell: Sounds like you've had some challenges... many people have similar ones.What are your thoughts about trying again, perhaps with help to address the challenges?
Kevin: I mean, maybe, maybe not. Don't really feel like what I tried before is gonna help in the future.And either way, the tricky part is time.
Kevin: Problem is...
Kevin: When I come home, all I wanna do is have a chance to relax for a sec - you know,kick my feet up, lie down on the couch. I don't really wanna do anything strenuous.
Nurse Practitioner Bell: I can tell you a few ways you can manage your time better.
Kevin: Yeah, OK. Well, you're the expert. I guess...
Coach: Instead of offering advice, Nurse Practitioner Bell can consider engaging and collaborating with Kevin by exploring his ideas for freeing up time.
Nurse Practitioner Bell: Now let's talk about how important making a change is to you to overcome these challenges.
Kevin: Really? O....kay...
Coach: Though exploring importance is a great way to look at motivation, it would be better to for Nurse Practitioner Bell to reflect and summarize what she has learned so far before moving on.
Nurse Practitioner Bell: So we talked a bit about how you might make some changes in diet and exercise.Would it be ok if we talked about some weight loss programs that may work for you?
Kevin: I... maybe. I guess I'm still a little concerned with thetime it will take to actually engage in the program. But whaddya got?
Coach: Though Nurse Practitioner Bell supported Kevin's autonomy by asking permission, a better way to gauge Kevin's readiness would've been to use the Importance Scale.
Nurse Practitioner Bell: You should join the MOVE! program. Do you know what that is?
Coach: Rather than telling Kevin that he "should" join the MOVE! program, which is directive and has a judgmental tone, Nurse Practitioner Bell can try to avoid the use of "shoulds" and instead ask Kevin about his understanding and interest in a weight management program.
Kevin: MOVE!? MOVE!?!
Nurse Practitioner Bell: It's the VA's weight management progra--Oh, I know what MOVE! is, all right! I've TRIED the MOVE! program before. It... didn't end well.
Nurse Practitioner Bell: What happened?
Kevin: I didn't like the group sessions, I hated the crappy food they suggested,and I ended up quitting almost as soon as I started.
Coach: Kevin had a bad experience with the MOVE! Program. Nurse Practitioner Bell can consider exploring his experience to learn whether there are ways his concerns about participating can be addressed.
Nurse Practitioner Bell: It's not easy to speak within a group, that's true.
Kevin: Particularly about things I don't want to speak about. Like this subject, for instance...
Coach: Even though Nurse Practitioner Bell acknowledged how difficult it is to speak in groups, she prompted sustain talk from Kevin. She can considering asking to share additional information about the MOVE! program.
Kevin: I had a feeling this was gonna just be the same as last time....
Nurse Practitioner Bell: Sometimes healthy food takes some... getting used to. But at least it's healthy.
Kevin: If staying healthy means eating a lot of salads versus... anything else at all... I'd rather the anything else.
Coach: Nurse Practitioner Bell’s comment disregarded Kevin's food preferences. It'd be better to encourage Kevin to share more about his experience with the program and explore options that work for him.
Kevin: Look, I know you're trying to sell me this thing. But I'm just not buying it.
Kevin: The MOVE! program just isn't for me, sorry.
Nurse Practitioner Bell: If you don't want to do the MOVE! program,you really need to pick some sort of exercise that will help you lose weight.
Kevin: Yeah, I know. It's just the time factor...
Nurse Practitioner Bell: You need to make exercise a priority!
Kevin: That's easy to say... hard to do!
Coach: By pushing Kevin to exercise, he felt like Nurse Practitioner Bell was not working alongside him. She can try harder to treat him as a collaborative partner and brainstorm exercise options together.
Nurse Practitioner Bell: You mentioned your treadmill earlier... any way you can lose weight will help your lower your A1C levels.
Kevin: Well, I used to enjoy running... and helping my wife with the cooking... when I can actually fit it in.
Nurse Practitioner Bell: That can work... Any time you devote to exercise and eating wisely can pay off.
Coach: It's good Nurse Practitioner Bell connected weight loss with a decrease in A1C levels. She can also take it further by eliciting other exercise ideas Kevin has, providing information to support his goals, and asking how those ideas fit into his lifestyle.
Nurse Practitioner Bell: Losing just 5% of your body weight can help get those A1C levels lowered.So at 256 pounds, we're looking at... around 13 pounds. You'd be less tired, and...
Nurse Practitioner Bell: ...be there for your wife!
Nurse Practitioner Bell: How does that sound?
Nurse Practitioner Bell: Let's work on setting a goal together.
Kevin: OK.
Coach: Though Nurse Practitioner Bell’s choice to set a goal is valuable, she missed an opportunity to collaborate with Kevin on setting a SMART goal, one that is behaviorally Specific, Measurable, Action-oriented, Realistic and has a Timetable to complete.
Nurse Practitioner Bell: Is there a goal in mind you'd like to achieve?
Nurse Practitioner Bell: Start steppin' on the treadmill... when I have some time?
Nurse Practitioner Bell: Sounds like a good start! There might be a way to evolve the goal into what we call a "SMART" goal- I can explain further, if that's okay with you?
Kevin: Sure!
Nurse Practitioner Bell: Each letter of "SMART" stands for something about the goal.Specific, measurable, action-oriented, realistic, and time-based.
Kevin: Well, I like the realistic part...
Nurse Practitioner Bell: OK, well, what's something you think might be realistic then?
Coach: Good! Nurse Practitioner Bell asked Kevin for permission to share information, which respects Kevin's autonomy and encourages collaboration. In addition, she took the time to explain SMART goals to help Kevin succeed in making a change.
Kevin: Doing say... 30 minutes of treadmill... like.. 3 times a week?
Nurse Practitioner Bell: Sounds pretty SMART to me!
Nurse Practitioner Bell: Nice work. Well, I guess we're all done here.
Kevin: Thanks for your time. I appreciate it. I'll remember what we talked about here today.
Nurse Practitioner Bell: That's great to hear, Kevin. Good luck with the exercise!
Kevin: Thanks!
Nurse Practitioner Bell: No problem! See you in three months at our next appointment!
Kevin: See you then!
Coach: Kevin feels like he can only address his weight on his own. He postpones his next visit with Nurse Practitioner Bell. When they do meet again, Kevin is willing to talk about his weight management - but he has gained weight.
Lisa Crane is a 45-year-old veteran who was diagnosed five years ago with Type 2 diabetes. She often forgets to take her medication, does not exercise, and no longer checks her blood sugar regularly or follows diabetes dietary guidelines.
She usually comes in every three months, but last month, she had to reschedule because one of her three children was sick at home. You will hear four different examples of Nurse Practitioner Bell’s check-in with Lisa today where they will collaborate on some solutions to some of the problems that Lisa is encountering.
The goals for this conversation are:
Notice when Nurse Practitioner Bell is successfully working towards the conversation goals and when she struggles. You will also hear feedback from the coach who will give you a sense of what Nurse Practitioner Bell is doing well and where she can make improvements. As before, the last two examples use more advanced MI techniques.
Nurse Practitioner Bell: Hi Ms. Crane, it's good to see you again.
Lisa: Call me Lisa, and yeah, good to see you too, Nurse Practitioner Bell. Sorry, I meant to get myself here last month, things have just been busy at home.
Nurse Practitioner Bell: I know how that can be. I'm glad you're here now.
Nurse Practitioner Bell: You know, I don't think I've asked before, what branch did you serve with?
Coach: Nurse Practitioner Bell did a nice job asking a question about Lisa's service. This allows her to build a personal connection by expressing respect for Lisa’s service.
Lisa: Well, I was in the Marines from '80 to '84, and then I did some time in the Coast Guard.
Nurse Practitioner Bell: Sounds like an interesting military career. What was that transition like?
Lisa: Not bad. It helps I have solid sea legs.
Nurse Practitioner Bell: That makes sense.
Nurse Practitioner Bell: All right, let's get started.
Nurse Practitioner Bell: What would you like out of today's visit?
Coach: Nice! An open-ended question like this is an effective way to set an agenda and learn about Lisa's needs. By letting Lisa decide what she would like to discuss, Nurse Practitioner Bell opened the discussion to concerns that she may have.
Lisa: Talk a little about my diabetes, I guess. I've been feeling pretty good,but I haven't really been looking after myself recently.
Nurse Practitioner Bell: So, you'd like to address your diabetes... and it sounds like you've had some trouble caring for yourself.
Lisa: Yeah, I- I feel tired, and... sometimes I forget to take my meds. I know, I've been told before how important it is...
Lisa: But I'm so busy, it kind of... gets lost. It's just not what I'm usually thinking about.
Nurse Practitioner Bell: You're in control here. We can use this visit however you want to use it.
Lisa: Yeah, I know. My mom's been bugging me to come in. Says it's "good for me". It's just so hard, you know?For a while things were looking up, I lost ten pounds. But then... I gained it all back.There's just- there's so much going on. So I make do.
Coach: Great! By emphasizing Lisa's autonomy, Nurse Practitioner Bell showed she values Lisa’s time and concerns.
Nurse Practitioner Bell: Losing ten pounds is a big accomplishment.
Lisa: Thanks. I- I felt pretty good about it. I'll think about getting back into it, when I'm feeling less... tired.For now, I'm getting on with what I got.
Coach: Using an objective affirmation like, "losing ten pounds is a big accomplishment" is a good way to help Lisa feel empowered, open to continuing this conversation, and, potentially, more receptive to change .
Nurse Practitioner Bell: I hear you've been busy, and it's a challenge to take your medications regularly, yet you know it's important.
Lisa: Yeah, I get how I should be taking my meds. But it's hard, you know?
Coach: Great. Using this double-sided reflection recognizes and validates Lisa's concerns and reflects Lisa's interest in "keeping up" with meds. Noticing and reflecting change talk evoked more change talk to from Lisa.
Lisa: I mean... for the past... I don't know how long, I've had so much on my mind.My kids always need to be driven from place to place, my mom is always critical of how I'm living my life,and I'm working long hours at the diner... which throws me out of whack.
Nurse Practitioner Bell: Sounds like you have a lot going on - it's understandable that's impacting both you and your diabetes.
Lisa: Right.
Nurse Practitioner Bell: Can we can explore those areas of your life a bit more, and see how they might be connected to your health?
Lisa: Sure. Why not.
Nurse Practitioner Bell: How does your work schedule, "throw you out of whack," like you said?
Lisa: Well, it all adds up... money is a little hard to come by these days, so I kind of have to take the shifts I can get.And after being on my feet for sixteen hours, working a double... I just don't have much left in me.
Nurse Practitioner Bell: It seems like you're working hard to support your family.
Lisa: I try my best. After my loser ex went off and... did what he did, what was I supposed to do?Sometimes it can really feel like it's me against the world.
Coach: Nurse Practitioner Bell made a great choice to offer an affirmation about Lisa's efforts to support her family! It led to Lisa's disclosure of other important information about her situation that will help them both collaborate on a plan.
Nurse Practitioner Bell: I hear how tiring work can be. What are things like after you get home?
Lisa: Well, I try to talk with my mom, or play with the kids. That helps me unwind a little.But then there's always dishes to do, food to cook, kids need help with homework,my mom has an errand she's too tired to run... after all that, I might get a little time to myself.
Lisa: Things just... add up for me. And to make it all worse, I don't usually get a good night's sleep.
Nurse Practitioner Bell: Tell me more about that.
Lisa: Well... after I finally get the kids down I try to lie down,but just when I start to fall asleep, I usually have to use the bathroom.And that wakes me up throughout the night, too.I mean, I'm used to getting bladder or yeast infections a couple times a year, and that would keep me up.But now it's a regular thing... it's awful.
Nurse Practitioner Bell: That sounds frustrating.
Lisa: Yeah. And... it's a bit embarrassing to even be talking about it. But not getting enough sleep definitely adds up.
Nurse Practitioner Bell: It seems like this has been part of a pattern of feeling more tired recently.
Lisa: It's... been a hard couple years. It's not always easy to see, when you're in the middle of a shitstorm.I mean, it was like... I get diabetes, my dad dies, and my husband starts cheating on me, boom, boom, boom.Then there I am, all alone, with four people depending on me.So, I did what I had to. Even if it meant putting my own needs to the side.
Nurse Practitioner Bell: So you've been focusing on others' needs before your own,yet you realize there might be more you could do for yourself.
Lisa: Yeah. I guess we can talk about that a bit. Unless there's something else you wanted to talk about?
Coach: Offering an affirmation about Lisa's efforts to support her family led to Lisa's disclosure of other important information about her situation that will help in collaborating with her on a plan.
Nurse Practitioner Bell: It sounds like your kids have been wearing you out recently.
Lisa: Well, I love 'em, but- getting them where they're going can be... a lot, sometimes.
Lisa: Gracie's got dance, Tucker's got football practice, and Rita... she's always at some friend's house.But of course, they need mama to take the time, AND the money, to give them a ride...
Lisa: My mom tries helping, but she doesn't like driving so much any more,and don't even get me started about my ex.Being a good momma really is like a second job. That you don't get paid for.
Nurse Practitioner Bell: You're doing an awful lot to be there for your kids.
Lisa: I'm trying my best.
Nurse Practitioner Bell: It seems like your kids have been especially tiring lately, maybe more than usual.
Coach: Great! By reflecting Lisa's tiredness, Nurse Practitioner Bell showed her she was earnestly listening and trying to understand her perspective.
Lisa: Could be. Things have been busy, that's for sure...
Coach: Great! Nurse Practitioner Bell used a reflection about how busy Lisa is and followed it with an open-ended question that tapped into her motivation for self-care. Note how this choice also opened the door for Lisa to bring up other concerns.
Nurse Practitioner Bell: I hear you're busy with your kids. How are you taking time to care for yourself, look after your own health?
Lisa: I- I don't know. I got a babysitter... last month, and took an aerobics class a friend was teaching,but- It's been a little while. There's just not enough time, with everything I have to do for my kids.
Lisa: I guess... sometimes I can get lost in taking care of my kids instead of taking care of myself.
Nurse Practitioner Bell: That seems pretty understandable.
Lisa: Yeah, I'm starting to see that things have been more difficult recently. I'm good, unless there's more to talk through?
Nurse Practitioner Bell: How has it been, having your mom with you?
Coach: Great open-ended question to explore Lisa's experience. Since this is a personal topic for Lisa, Nurse Practitioner Bell may want to use reflections to show Lisa she is listening, and let her be the one to decide if she wants to share more.
Lisa: Well, it's never been easy talking to her. But with everything else going on, it's really started to wear me down.I mean... I know how much she cares about me, and the kids.After my loser husband moved out, she moved in to help out.But it's just brought up a lot of... old stuff between us.She's constantly making comments about how I look, or what I'm doing.It's not the best feeling, hearing that every day.
Nurse Practitioner Bell: It sounds like... maybe not in the best way, your mom wants you to stay healthy.
Coach: Nice! By reflecting what Lisa has told her about her mom, including reframing her mom's efforts, Nurse Practitioner Bell helped Lisa focus on her mom as a potential source of support.
Lisa: She... worries about me. Even when what she's saying is pretty critical, I know where her heart is.She's... one of the big reasons I came in today.
Nurse Practitioner Bell: So your mom can be critical, which is irritating, and at the same time, wants you to stay healthy.
Lisa: Yeah, she can be a real pain, but I don't know,she's lived with diabetes for a while, and she knows what could happen.
Coach: Great double sided reflection! Nurse Practitioner Bell accurately reflected Lisa's feelings while also reflecting Lisa's perception that her mom wants her to be healthy.
Lisa: I do get what you're saying. She's prolly trying to help, whether or not it comes off that way.
Nurse Practitioner Bell: Well, you know your mom better than I do. From what you said, it seems like she's trying to be an ally,especially as you both continue living with your diabetes together.
Lisa: She's really been on a kick, recently. Not sure why she decided to start cranking it to eleven.Honestly... part of the reason I came today was to shut her up.
Nurse Practitioner Bell: That sounds pretty draining.
Lisa: Yeah... She's so... critical of how I live my life.
Lisa: All right, I can definitely see how things have been more difficult recently.Thanks for talking everything through with me. I'm good.
Nurse Practitioner Bell: Okay, let's move on then.
Nurse Practitioner Bell: After all that you've talked about, you still made time to come in today.I think it's great you're putting this much effort into staying healthy.
Lisa: Thanks.
Lisa: It's a lot to keep up with.
Lisa: I know I should be doing a better job of taking care of myself. It can just be hard to... make the time.
Nurse Practitioner Bell: What do you know about how your diabetes might be affecting how you've been feeling?
Lisa: Well, I know if my blood sugar levels aren't where they're supposed to be then I'm going to feel pretty out of it...I don't remember all the details though. That's why I come see you, right?
Nurse Practitioner Bell: Hopefully not the only reason. And yes, you're right, your blood sugar levels can impact how you feel.
Lisa: See, there you go.
Nurse Practitioner Bell: Can we discuss how diabetes might be affecting your fatigue?
Lisa: Sure... I don't see why not.
Coach: Good! Checking with Lisa before sharing information encourages collaboration and prepares Lisa to be more likely to understand the information.
Nurse Practitioner Bell: So, when you have diabetes and your blood sugars are running high,it means your muscles and organs aren't getting the energy they need and you feel tired.The medications help your body to use the sugar in your blood to give you the energy you need keep you going.
Nurse Practitioner Bell: High blood sugar levels increase the amount of urine you produces it may explain why you've been needing to use the bathroom at night.
Nurse Practitioner Bell: What do you think of that?
Lisa: Gotcha. I've heard that before, but it's good to hear it again, remind myself what's going on. Thanks.
Coach: Nurse Practitioner Bell did a nice job asking for permission, then sharing information in a clear way that Lisa could understand. She was more willing to listen, and likely got a better sense of what Nurse Practitioner Bell was trying to convey.
Nurse Practitioner Bell: I want to make sure the information I shared was clear.So, please tell me what you understood about how diabetes could be affecting your health?
Lisa: Well, if I don't take care of myself and eat well, take meds, exercise or what have you...
Lisa: it can mean my body won't be able to have the energy, uh, blood sugars it needs to keep me going.
Coach: Nurse Practitioner Bell did a nice job asking Lisa to share what she understood in a way that suggested any misunderstanding might be due to her lack of clarity. Because she shared information clearly and without jargon, Lisa understood and could clearly connect the information to her situation.
Lisa: And also, my trips to the bathroom at night could be from my blood sugars being too high.
Nurse Practitioner Bell: You have a solid understanding of how taking care of both yourself and your diabetes can help you stay well.
Lisa: Thanks. I think so too.
Nurse Practitioner Bell: On a scale from zero to ten, how important is it for you to work on managing your diabetes,with zero being not at all important and ten being extremely important?
Coach: Nurse Practitioner Bell did a nice job using the Importance Scale! This gave Lisa a chance to reflect on how important it is to her to make a behavior change and express change talk. It also provides an opportunity for Nurse Practitioner Bell to respond to her motivation.
Lisa: I'd say... a seven.
Nurse Practitioner Bell: What makes you choose a seven...
Nurse Practitioner Bell: ...instead of a lower number, like a three?
Coach: This gave Lisa a chance to reflect on how important it is to her to make a behavior change and express change talk.
Lisa: I- I'm not ready to die. I still have a lot of life in me, you know?And after the kids all leave the house... who knows?
Nurse Practitioner Bell: It sounds like you have a lot more you'd like to do in your life.
Lisa: Exactly. After all I've been through, to have diabetes take me down? And... I could see myself travelling, maybe.
Coach: Great reflection! It led to Lisa sharing reasons to stay healthy - change talk.
Lisa: If I don't do anything about my diabetes...I know I might not get much time after the kids are all grown up to visit Italy, or what have you.
Nurse Practitioner Bell: You deserve a chance to enjoy your life, after all you've been through.
Lisa: I mean, seriously?! After serving in the marines, surviving my marriage,I'm gonna die cause of diabetes? I don't think so.
Nurse Practitioner Bell: With that attitude, I wouldn't be surprised to see you sitting in an Italian cafe.
Lisa: I'd enjoy that... who knows?
Coach: Good affirmation!
Nurse Practitioner Bell: So let's talk a bit more about how we can keep you healthy.
Lisa: Sounds good.
Nurse Practitioner Bell: Let me go over what we've talked about so far, to make sure we're on the same page.
Lisa: Okay.
Nurse Practitioner Bell: So far I'm hearing you've been busy...
Nurse Practitioner Bell: Looking after your three kids...
Nurse Practitioner Bell: Taking care of your mom...
Nurse Practitioner Bell: Working your job at the diner...
Nurse Practitioner Bell: and you want to try to take better care of your own health because...
Nurse Practitioner Bell: ... you want to live a long, full life.
Lisa: Yeah. I'm not going down that easy! Still got a lot more life in me.
Coach: Nurse Practitioner Bell did a nice job correctly identifying Lisa's most important motivation! This made her feel heard and intrinsically motivated to make a behavior change.
Lisa: Thanks. I guess it was good I came in today.I'm not sure I would have been able to see all that put together without your help.
Nurse Practitioner Bell: Well, thanks for talking everything through with me so far.Sounds like we're ready to figure out how to make healthy choices work better with your routine.
Coach: Nurse Practitioner Bell chose to move on to making a plan before Lisa had fully explored her motivation.
Lisa: Sounds good to me!
Nurse Practitioner Bell: How do you think you could take steps to better manage your diabetes?
Coach: Nurse Practitioner Bell did a nice job using open ended questions to explore Lisa's ideas, instead of being directive or lecturing her.
Lisa: I know I should look after myself better.
Lisa: It's hard to remember to take my meds, and check my sugars.It's discouraging... and my schedule is so all over the place.But it seems like it won't take as much time as getting more exercise or what have you, so I'd rather focus on that.
Nurse Practitioner Bell: I hear you saying you're discouraged because you really would like to take the medication more regularly and check your sugars, despite the challenges you mentioned.I'm happy to work with you to come up with some ways that might help.
Lisa: Thanks for noticing... maybe we can start with the medications.It would be good to make it easier to remember, even when I get busy.
Nurse Practitioner Bell: What are some of your obstacles to regularly taking your medication?
Lisa: I'm so busy keeping track of each of my kids' schedules that- I guess I lose track of my own.
Nurse Practitioner Bell: How do you stay on top of your kids' schedules?
Lisa: I- it might be a little silly, but... I print out this calendar, and color code it for each kid.They got to choose the colors, which makes them happy. And then I know what's going on, you know?
Nurse Practitioner Bell: It sounds like you use that calendar to keep track of a lot of info.
Lisa: My mom used to do something similar for us. She used to draw hers on big paper, tack it up to the wall.I make mine on the computer. Keeps things more organized, I think.
Nurse Practitioner Bell: Seems you know what you're doing.
Lisa: Yup. I'd say so.
Nurse Practitioner Bell: You keep track of a lot of people's schedules, which seems like a strength of yours.
Lisa: Yeah, I am pretty good at staying on top of other people. I guess, starting with the new calendar next week,I could put something on the calendar every day in my own color at the times I need to take my meds.I could even do that before I printed it out!
Nurse Practitioner Bell: That sounds like a great plan.
Lisa: I'm pretty good with computers... came from my time in the Coast Guard,banging out the paperwork every time I had to write up some drunken incident at a seaside bar! That makes sense! Anything else that would help you to remember to take your medications?
Lisa: If I keep in mind why I'm doing it... staying healthy, that is... it might help me stick to the plan.
Nurse Practitioner Bell: Like having a long, full life.
Lisa: Exactly.
Lisa: I gotta see my kids through flapping their wings and leaving, so I can be kid free!I say that instead of empty nester.
Nurse Practitioner Bell: Makes sense.
Coach: Nurse Practitioner Bell did a nice job correctly identifying Lisa's most important motivation! This made her feel heard and intrinsically motivated to make a behavior change.
Lisa: Y'know, I thought you were going to come in and give me a big ol' lecture today.I'm glad you're not that kind of person.
Nurse Practitioner Bell: Thanks. You know more about what works well for your family than I ever will.
Nurse Practitioner Bell: I'd like to work together and set a goal that you can work toward. How's that sound?
Lisa: Okay, that sounds good. What kind of goal?
Nurse Practitioner Bell: One that's clearly defined, achievable, and beneficial to your health.
Lisa: Understood.
Nurse Practitioner Bell: To build on what we were just talking about, in regard to your diabetes management,what would be a specific, realistic goal over the next three months?
Lisa: Well...
Lisa: The most important thing for me would be, starting with the new calendar next week,I could put my med schedule up in my own color, and really make an effort to take my medication.
Nurse Practitioner Bell: That makes sense.
Nurse Practitioner Bell: No change is too small here. Any change you make is a step toward being healthier.
Lisa: That's good to keep in mind, and less pressure is a bit of a weight off my shoulders... thanks.
Nurse Practitioner Bell: When would be a good time for me to check in on how things are going?Ha. I don't know, my schedule is all over the place. A call might be a little tricky. Any other options?
Nurse Practitioner Bell: You're welcome to send a secure text message to update me on the plan.
Lisa: Okay, I should be able to shoot you a quick text next week.
Nurse Practitioner Bell: Sounds good.
Coach: It was a great idea to ask about preferences for follow-up to the plan. It increases the likelihood of follow through and provides an opportunity for subsequent problem-solving.
Nurse Practitioner Bell: On a scale from zero to ten, with zero being not at all confident and ten being extremely confident, how confident do you feel about sticking to your goal?
Lisa: I would say... a seven. Out of ten.
Coach: Good! Assessing confidence using the scale allowed Nurse Practitioner Bell to get a sense of where Lisa is in her confidence and will help you to further explore both her feelings of empowerment as well as her barriers to success.
Nurse Practitioner Bell: What makes you say a seven instead of a lower number like a five?
Lisa: I'm pretty disciplined, I know how to push myself and stick to a plan. Comes from my years in the service.
Coach: Nice! By asking what contributed to her rating versus a lower number, Nurse Practitioner Bell helped Lisa focus on positive attributes and strengths that provide bolster empowerment, while also providing her with opportunities for affirmation.
Lisa: And... I'm good at taking care of people, keeping track of my kids' schedules. I can take care of myself too.
Nurse Practitioner Bell: Who do you have to help you with managing your diabetes?
Lisa: No one, really. Just me.
Nurse Practitioner Bell: How would you feel about including your family more in that process?
Lisa: I mean... I don't want to burden them. But I see what you're saying.Maybe I could sit down with my mom, see if she'd be willing to help set the kids up with cereal in the morning,so I could be sure to have time to take my pills.
Nurse Practitioner Bell: So even a little more time could make a big difference.
Lisa: It's worth a shot.
Coach: Great! Asking open-ended questions about sources of support provides an opportunity to increase openness to an action plan.
Nurse Practitioner Bell: You do an impressive job of taking care of people, and I'm sure you'll be able to look after your health too.
Lisa: Thanks. I hope so.
Nurse Practitioner Bell: What would it take to make you more confident, closer to an eight or a nine?
Lisa: I don't know, with me spread so thin... there's just a certain amount that I have to accept I can't do.But... I guess I'd be more confident if I had some time in the morning, when I'm getting the kids ready for school.
Nurse Practitioner Bell: Ah, I can see why that would be a challenge. What could you do to address that barrier?
Lisa: Hmm... maybe I could set my alarm ten minutes earlier than I do now and really try not to hit the snooze button,so I can take my pills before I have to wake my kids up.
Nurse Practitioner Bell: That seems like a good way to stay on top of taking your medication.
Lisa: Yeah... cause once I'm fighting with my oldest to get herself out of bed, that's the rest of my morning, gone!
Coach: Good. By asking what will help her be more confident, Nurse Practitioner Bell helped her identify a barrier and a solution to overcome the barrier!
Nurse Practitioner Bell: So, what else might get in the way of you meeting your goal of remembering to take your diabetes medication?
Lisa: Hmm... I guess at the end of the day I'm already tired, and I still have so much to do,cooking dinner, helping the kids with their homework, picking out what clothes to wear,you know how little girls can be about their outfits!
Nurse Practitioner Bell: I do! So any ideas about how to address that busy time?
Lisa: Well... maybe I can try to ask my oldest to help remind me to take my evening dose.For all her teenager ways, Rita can be pretty responsible!And it would be good to have something that she's doing to help me, so we're...on the same team sometimes. Not always at each other's throats.
Nurse Practitioner Bell: Sure. That sounds like it could help. So how might that happen?
Lisa: I can sit down with and chat tonight, when she gets home from practice.
Nurse Practitioner Bell: Sounds like a plan.
Coach: Good! After Lisa felt motivated to make a change, Nurse Practitioner Bell asked about challenges she might face and how she might prepare for them.
Nurse Practitioner Bell: Would it be okay if I go over what we talked about?
Lisa: Yup. I gotta get going.
Nurse Practitioner Bell: You're going to put your medication schedule on your family calendar...
Nurse Practitioner Bell: You'll try to set your alarm a little earlier, to help you take your medication in the mornings...
Nurse Practitioner Bell: You'll chat with your mom about helping with your kids' breakfast...
Lisa: You'll try to get your daughter to help remind you to take your evening pills...
Nurse Practitioner Bell: And you'll check your calendar and let me know when it would be a good time for a follow up appointment.How's that sound?
Lisa: Sounds good to me.
Nurse Practitioner Bell: Thanks so much for talking, Lisa. I look forward to hearing from you next week.
Lisa: All right. I'll text you an update then.
Coach: Lisa left her appointment with a plan to take her medication more regularly by putting it on her family calendar. Lisa felt empowered by her visit with Nurse Practitioner Bell, and followed through on her plan to better manage her diabetes. During Lisa's next appointment, her A1C levels had improved, and she said she was feeling a little less tired in general.
Nurse Practitioner Bell: Hi Ms. Crane, it's good to see you again.
Lisa: Call me Lisa, and yeah, good to see you too, Nurse Practitioner Bell:.Sorry, I meant to get myself here last month, things have just been busy at home.
Nurse Practitioner Bell: I know how that can be. I'm glad you're here now.
Nurse Practitioner Bell: It's important to check in with us every few months, for your health. What kept you from the last one?
Lisa: I- I had a lot going on. Not sure what, the days all kind of... blend together.
Nurse Practitioner Bell: I can understand that. Well, you're here now.
Coach: Nurse Practitioner Bell’s question, although well-intentioned, came off as more of an admonishment. An effective open-ended question's message is neutral and avoids judgement.
Lisa: Exactly.
Nurse Practitioner Bell: All right, let's get started.
Nurse Practitioner Bell: Today, we should focus on how you've been managing your diabetes.
Coach: By setting the agenda for the visit with Lisa, Nurse Practitioner Bell’s pushed her into a discussion she may not be interested in having. Asking an open-ended question about Lisa’s agenda would give her some control and help Nurse Practitioner Bell learn about the issues Lisa cares about.
Lisa: Okay... sure. I've been doing fine. As fine as I can be, that is.Sometimes... I don't remember to take my meds.And don't get on my case for that, I know I'm supposed to be taking 'em.
Lisa: But I'm so busy, it kind of... gets lost. It's just not what I'm usually thinking about.
Nurse Practitioner Bell: Maybe you could be eating healthier?
Lisa: What's that supposed to mean?
Nurse Practitioner Bell: I'm just trying to understand what's been making you tired.
Lisa: Well, you coulda just said that.
Nurse Practitioner Bell: Right. Sorry.
Lisa: Well...
Coach: This closed-ended question made an assumption about Lisa's eating habits. A neutral open-ended question would allow Nurse Practitioner Bell to explore Lisa's perceptions and ideas about contributions to her fatigue.
Lisa: I mean... for the past... I don't know how long, I've had so much on my mind.My kids always need to be driven from place to place, my mom is always critical of how I'm living my life,and I'm working long hours at the diner... which throws me out of whack.
Nurse Practitioner Bell: Sounds like you have a lot going on - it's understandable that's impacting both you and your diabetes.
Lisa: Right.
Nurse Practitioner Bell: Can we can explore those areas of your life a bit more, and see how they might be connected to your health?
Lisa: Sure. Why not.
Nurse Practitioner Bell: I think the best thing you can do right now is stay on top of your diabetes, which will make you feel less tired.
Lisa: Maybe, but I think my feelings of tiredness are mostly connected to... my tiring life.
Coach: While Nurse Practitioner Bell may want to prescribe the best course of action for Lisa, it's important to ask Lisa about her perceptions, ideas and feelings about her tiredness.
Nurse Practitioner Bell: Sorry to hear about how hard you've been working.
Lisa: When I was in the marines, I would work much longer hours hauling around a lot more weight than three burgers and a steak.Even riding the boat was a bigger deal a lot of the time.
Nurse Practitioner Bell: I see. So, the work itself is not that difficult for you.
Lisa: That's right. It's everything... all of it.
Coach: Though Nurse Practitioner Bell’s intention may have been to express compassion, the use of "sorry" was experienced as patronizing. Instead, she can try using reflections that seek to understand and give Lisa a chance to elaborate, like, "You have been working long hours."
Nurse Practitioner Bell: I think this job might be making it difficult for you to keep up with other things in your life.Are you looking for other job opportunities?
Coach: Though Nurse Practitioner Bell may have thought she was helping Lisa, she felt the suggestion was off-target. She can try using reflections and open-ended questions to explore her ideas/feelings to deepen understanding and foster collaboration.
Lisa: I- That's just not something I can afford to look into right now.
Nurse Practitioner Bell: Okay.
Lisa: You know what? I'm kinda tired of talking about my job. Let's just drop it.
Nurse Practitioner Bell: Uh, okay. You sure?
Lisa: Yes. I'm sure.
Nurse Practitioner Bell: So your kids are keeping you busy... that seems normal for a parent. How can you better manage that?
Lisa: It's not easy... I don't think you get how hard it is.
Nurse Practitioner Bell: Okay. Sorry.
Coach: Nurse Practitioner Bell’s effort to understand Lisa is admirable, but her reflection was off target and felt dismissive to Lisa. Instead, Nurse Practitioner Bell can consider validating her points of stress to help her feel understood and more willing to collaborate on a course of action.
Nurse Practitioner Bell: As far as I know, the best way you can be there for your kids is by looking after yourself.
Coach: Encouraging Lisa to focus on her own needs is admirable, though she finds Nurse Practitioner Bell’s advice dismissive. Instead, she can consider reflecting and validating her feelings to help Lisa feel understood and perhaps more willing to explore and collaborate on possible strategies and solutions.
Lisa: Easier said than done. It's hard to find time for both.
Lisa: I- You know what? Let's stop talking about my kids. If I'm being real, it's putting me a little on edge.
Nurse Practitioner Bell: Uh, okay. You sure?
Lisa: Yes. I'm sure.
Nurse Practitioner Bell: Your mom has a point, you should be looking after yourself.
Lisa: Really? You're taking her side?
Nurse Practitioner Bell: I'm not taking anyone's side. I'm just saying she's right, taking care of your health is important.
Lisa: Gotcha.
Coach: Nurse Practitioner Bell’s effort to help Lisa focus on her own needs is admirable, though instead of telling Lisa what she 'should do,' she can consider reflecting and validating her feelings and using questions to explore HER ideas for addressing her needs.
Nurse Practitioner Bell: I think your mom is in a tough situation, you know? This can't be easy on her.
Coach: Nurse Practitioner Bell’s choice to speak on behalf of Lisa's mom felt dismissive and critical to Lisa. Instead, she can try using open questions and reflections to explore Lisa's feelings and ideas about how she might manage her relationship with her mom.
Lisa: Uh huh.
Nurse Practitioner Bell: I've had fights with my mom before where we don't talk for... months. I don't want that to happen to you.
Lisa: I'm good. Thanks.
Lisa: Actually, I'm not really in the mood to talk more about my mom right now.
Nurse Practitioner Bell: Uh, okay. You sure?
Lisa: Yes. I'm sure.
Lisa: Honestly... I'm kind of tired of hearing you talk to me like that. What else do we have to talk about?
Coach: Nurse Practitioner Bell’s approach has led to too much discord for Lisa to feel open to discussing how her tiredness connects to her diabetes.
Nurse Practitioner Bell: What if you shared some of what you've told me with your mom?
Lisa: I've tried that... I- I didn't mean to start complaining like this. I appreciate you trying to help though.Having my mom around can get to be... a lot.
Coach: Nurse Practitioner Bell’s effort to address Lisa's challenges is admirable, though it would be better to reflect, validate and explore her ideas for responding to the issues she is facing.
Nurse Practitioner Bell: It sounds like... maybe not in the best way, your mom wants you to stay healthy.
Coach: Nice! By reflecting what Lisa has told her about her mom, including reframing her mom's efforts, Nurse Practitioner Bell has helped Lisa focus on her mom as a potential source of support.
Lisa: She... worries about me. Even when what she's saying is pretty critical, I know where her heart is.She's... one of the big reasons I came in today.
Lisa: I do get what you're saying. She's prolly trying to help, whether or not it comes off that way.
Nurse Practitioner Bell: Well, you know your mom better than I do. From what you said, it seems like she's trying to be an ally,especially as you both continue living with your diabetes together.
Lisa: She's really been on a kick, recently. Not sure why she decided to start cranking it to eleven.Honestly... part of the reason I came today was to shut her up.
Nurse Practitioner Bell: That sounds pretty draining.
Lisa: Yeah... She's so... critical of how I live my life.
Lisa: All right, I can definitely see how things have been more difficult recently.Thanks for talking everything through with me. I'm good.
Nurse Practitioner Bell: Okay, let's move on then.
Nurse Practitioner Bell: So, these feelings of exhaustion could be connected to high blood sugar levels,which are caused by both lack of enough insulin or insulin resistance.That means your body isn't responding to the insulin, and can't get the blood sugar into your cells.In addition, over time, high blood sugar levels cause vascular disease in both large and small vessels which makes it harder for blood to flow.
Nurse Practitioner Bell: What do you think of that?
Lisa: Well, I feel like you just went "all doctor" on me, which is never easy to get used to.But... I get what you're saying.
Coach: When Nurse Practitioner Bell shared information with too much jargon, especially without asking for permission first, Lisa had a harder time understanding and felt confused about how it related to her health. Using plain language can help foster both understanding and collaboration.
Nurse Practitioner Bell: I think there's more you can learn about how your diabetes is affecting your health.
Lisa: I'm fine. Thanks.
Nurse Practitioner Bell: It's just- based on the choices you've been making recently, I'm not sure that's true.
Lisa: You know what? I do have a solid understanding about what's going on. It's just... hard to do something about it.
Coach: Telling Lisa she had more to learn about her diabetes came off as condescending and disempowering. Nurse Practitioner Bell can consider asking more questions about her understanding and about her ideas for improving self-care to build motivation and confidence to make a change.
Nurse Practitioner Bell: Seems like we're ready to move on and talk a bit more about how diabetes is affecting your life.
Lisa: Yeah, gotta figure out some way to keep up with all this.
Nurse Practitioner Bell: We should chat a bit more about how you plan on managing your diabetes.
Coach: When Nurse Practitioner Bell tells Lisa what to talk about instead of asking her, she is less likely to be ready to collaborate. Also, she moved on to making a plan before Lisa had fully explored her motivation.
Coach: When Nurse Practitioner Bell tells Lisa what to talk about instead of asking her, she is less likely to be ready to collaborate. Nurse Practitioner Bell can try asking questions to foster more of an open dialogue about what to talk about.
Lisa: Sure.
Nurse Practitioner Bell: I have some ideas about how you can better manage your diabetes.
Lisa: Oh yeah? Well, I have some thoughts too.
Nurse Practitioner Bell: Oh, okay. Share away.
Coach: Even if Nurse Practitioner Bell thinks she knows what's best for Lisa, it's often better to use reflections and ask questions to let a patient feel in control of their own solutions. Lisa knows her situation better than anyone else! Asking Lisa to 'fire away' and share her ideas was a nice recovery.
Lisa: So, recently I've been thinking about...
Lisa: How much my family needs me. Don't know what they'd do without me, really.
Lisa: I know I should look after myself better.
Lisa: It's hard to remember to take my meds, and check my sugars.It's discouraging... and my schedule is so all over the place.But it seems like it won't take as much time as getting more exercise or what have you, so I'd rather focus on that.
Nurse Practitioner Bell: So you want to focus more on taking your medication, and then we can talk about exercise and diet.
Lisa: No, I just want to focus on my meds.
Nurse Practitioner Bell: Oh, okay. That's fine.
Nurse Practitioner Bell: If you set a timer on your phone, it might help you remember to take your meds.
Lisa: Yeah, I've tried that... when it goes off, I usually have to deal with whatever at hand.Screaming kid, argument with my mom, early shift at work...I have such a hard time keeping track of everything that I make this big, master calendar with everyone's schedules.It's kinda stupid, but... that's just what my life has come to.
Coach: By choosing a course of action for Lisa, Nurse Practitioner Bell is not giving her the space to come up with her own solutions, which she'd be more willing to stick to in the long term. Next time, consider asking her about ideas for remembering to take meds.
Nurse Practitioner Bell: And... why haven't you been using that calendar for yourself?
Lisa: I do, I write the shifts I'm working, so my family knows where I am.
Coach: Starting a question with "why" often adds an unwanted judgmental tone, and when Nurse Practitioner Bell asked about Lisa's calendar she felt like Nurse Practitioner Bell was implying she couldn't find her own solutions. Nurse Practitioner Bell can try using more reflections and open-ended questions to collaborate with Lisa.
Nurse Practitioner Bell: You should put your medication schedule on that calendar too.
Lisa: Doctors orders, huh.
Nurse Practitioner Bell: Just trying to problem solve.
Lisa: I mean... I'll think about it. And go with something that works best for me.
Nurse Practitioner Bell: You sure you-Yeah, I'm good.
Coach: Words like "should" can make us appear pushy and unwilling to consider other options. Instead of giving an opinion, Nurse Practitioner Bell can try asking Lisa to brainstorm her own solutions. If it is her idea, it is more likely lead to a plan she'll be able to stick to long term.
Lisa: If I keep in mind why I'm doing it... staying healthy, that is... it might help me stick to the plan.
Nurse Practitioner Bell: Like having a long, full life.
Lisa: ... sure. I guess that'll help me.
Nurse Practitioner Bell: Tell me your goal for the next few months. It should be specific and realistic.
Lisa: Pfft... uh, "yes ma'am".
Lisa: Well...
Coach: Asking Lisa to set a specific and realistic goal at this point is somewhat premature and directive. It would be better and more collaborative to ask permission to focus on a goal, which supports her autonomy and may increase buy-in.
Lisa: The most important thing is figuring out a way to take my meds better.
Nurse Practitioner Bell: That makes sense.
Nurse Practitioner Bell: I'm sure if you try really hard, you'll be able to take care of yourself, just like you take care of your family.
Lisa: Sure.
Coach: Using vague encouraging language makes Lisa feel like Nurse Practitioner Bell doesn’t understand or care about her as an individual. Next time, she can try being more specific when making an affirmation.
Nurse Practitioner Bell: I think you're going to be able to stick with your goal this time around.
Lisa: I'm gonna try.
Coach: Nurse Practitioner Bell may be aiming to encourage Lisa, though the statement has a patronizing tone. Instead, she can consider affirming Lisa’s past efforts and interest in self-care to help Lisa feel empowered, with less risk of feeling judged.
Nurse Practitioner Bell: Would it be okay if I go over what we talked about?
Lisa: Sure, go right ahead.
Nurse Practitioner Bell: You'll figure out a plan to take your medication that works for you...
Nurse Practitioner Bell: And hopefully I'll see you at your next appointment. Right?
Lisa: ... Sure. Thanks.
Nurse Practitioner Bell: Happy to help.
Coach: Lisa left her appointment with an intention to figure out how to be better at taking her medication. Lisa felt frustrated by her conversation with Nurse Practitioner Bell, and missed her next appointment. When she showed up a few months later, her A1C levels had gotten higher, she did not report any changes in behavior, and she said she was feeling even more tired since her last visit.
Nurse Practitioner Bell: Hi Ms. Crane, it's good to see you again.
Lisa: Yeah, same. And Lisa's fine. Can we get started? I got a lot on my plate today.
Nurse Practitioner Bell: Sure thing.
Nurse Practitioner Bell: I hear you have a lot to do today and want to make sure we don't keep you too long.
Lisa: Yeah, thanks. I have to pick up my kids so my friend can get to work.
Nurse Practitioner Bell: Thanks for letting me know. I'll make sure we finish on time.
Lisa: We don't have to rush, or anything. Just don't want to go over.
Coach: Nurse Practitioner Bell did a good job using a reflection here! She helped Lisa feel heard and helped build her confidence in your ability to listen and collaborate with her.
Nurse Practitioner Bell: All right, let's get started.
Nurse Practitioner Bell: What would you like out of today's visit?
Coach: Nice work! An open-ended question like this is an effective way to set an agenda and learn about Lisa's needs. By letting Lisa decide what she would like to discuss, Nurse Practitioner Bell opened the discussion to concerns that she may have.
Lisa: I don't know, I'm not sure what to say. I'm doin' fine. Nothing wrong with me, really.
Nurse Practitioner Bell: Glad to hear you're feeling well. So how could we use this visit to keep you healthy?
Lisa: Look, I don't even know if I want to be here. It's hard for me to think about this with so much on my mind.And now you're probably going to start suggesting ways to make it all better with "what if" scenarios...
Nurse Practitioner Bell: I promise, I won't suggest any quick fixes. What did you mean, that there's so much on your mind?
Lisa: It's just... tiring. So it's hard to keep up with my meds, and the like.
Nurse Practitioner Bell: You're in control here. We can use this visit however you want to use it.
Lisa: Yeah, I know. My mom's been bugging me to come in. Says it's "good for me". It's just so hard, you know?For a while things were looking up, I lost ten pounds. But then... I gained it all back.There's just- there's so much going on. So I make do.
Coach: Great! By emphasizing Lisa's autonomy, Nurse Practitioner Bell showed she values Lisa’s time and concerns.
Nurse Practitioner Bell: Losing ten pounds is a big accomplishment.
Lisa: Thanks. I- I felt pretty good about it. I'll think about getting back into it, when I'm feeling less... tired.For now, I'm getting on with what I got.
Coach: Using an objective affirmation like, "losing ten pounds is a big accomplishment" is a good way to help Lisa feel empowered, open to continuing this conversation, and, potentially, more receptive to change .
Nurse Practitioner Bell: I hear you've been busy, and it's a challenge to take your medications regularly, yet you know it's important.
Lisa: Yeah, I get how I should be taking my meds. But it's hard, you know?
Coach: Using this double-sided reflection recognizes and validates Lisa's concerns and reflects Lisa's interest in "keeping up" with meds. Noticing and reflecting change talk evoked more change talk to from Lisa.
Lisa: I mean... for the past... I don't know how long, I've had so much on my mind.My kids always need to be driven from place to place, my mom is always critical of how I'm living my life,and I'm working long hours at the diner... which throws me out of whack.
Nurse Practitioner Bell: Sounds like you have a lot going on - it's understandable that's impacting both you and your diabetes.
Lisa: Right.
Nurse Practitioner Bell: Can we can explore those areas of your life a bit more, and see how they might be connected to your health?
Lisa: Sure. Why not.
Nurse Practitioner Bell: How does your work schedule, "throw you out of whack," like you said?
Lisa: You know, just... what a long day of work does to you. Kicks your ass, makes your head spin.
Nurse Practitioner Bell: It seems like you're working hard to support your family.
Lisa: I don't know about all that. Just taking things a day at a time.
Nurse Practitioner Bell: I hear how tiring work can be. What are things like after you get home?
Lisa: Well, I try to talk with my mom, or play with the kids. That helps me unwind a little.But then there's always dishes to do, food to cook, kids need help with homework,my mom has an errand she's too tired to run... after all that, I might get a little time to myself.
Coach: Nurse Practitioner Bell made a great choice to offer an affirmation about Lisa's efforts to support her family! It led to Lisa's disclosure of other important information about her situation that will help both of you collaborate on a plan.
Lisa: Things just... add up for me. And to make it all worse, I don't usually get a good night's sleep.
Nurse Practitioner Bell: Tell me more about that.
Lisa: Well... after I finally get the kids down I try to lie down,but just when I start to fall asleep, I usually have to use the bathroom.And that wakes me up throughout the night, too.I mean, I'm used to getting bladder or yeast infections a couple times a year, and that would keep me up.But now it's a regular thing... it's awful.
Nurse Practitioner Bell: That sounds frustrating.
Lisa: Yeah. And... it's a bit embarrassing to even be talking about it. But not getting enough sleep definitely adds up.
Lisa: But that's just one part of it, you know?
Nurse Practitioner Bell: So there are some other parts of your life you'd like to discuss.
Lisa: Well... yeah, I guess.
Coach: Starting a question with "why" may add an unwanted judgmental tone. Also, by suggesting a specific solution, Nurse Practitioner Bell missed an opportunity to empower Lisa to explore her own ideas about remembering to take her medication.
Nurse Practitioner Bell: It sounds like your kids have been wearing you out recently.
Lisa: Gracie's got dance, Tucker's got football practice, and Rita... she's always at some friend's house.But of course, they need mama to take the time, AND the money, to give them a ride...
Lisa: What am I supposed to do?
Nurse Practitioner Bell: It seems like your kids have been especially tiring lately, maybe more than usual.
Coach: Great! By reflecting Lisa's tiredness, Nurse Practitioner Bell showed her she was earnestly listening and trying to understand her perspective.
Lisa: Maybe? I don't really even have time to think about what things used to be like.Farthest ahead I look is what I have coming up in a few hours,and without a calendar I have no idea what happened last week.
Nurse Practitioner Bell: I hear you're busy with your kids. How are you taking time to care for yourself, look after your own health?
Lisa: I- I don't know. I got a babysitter... last month, and took an aerobics class a friend was teaching,but- It's been a little while. There's just not enough time, with everything I have to do for my kids.
Coach: Great! Nurse Practitioner Bell used a reflection about how busy Lisa is and followed it with an open-ended question that tapped into her motivation for self-care. Note how this choice also opened the door for Lisa to bring up other concerns.
Lisa: I guess... sometimes I can get lost in taking care of my kids instead of taking care of myself.
Nurse Practitioner Bell: That seems pretty understandable.
Nurse Practitioner Bell: It seems like this has been part of a pattern of feeling more tired recently.
Lisa: It's... been a hard couple years. It's not always easy to see, when you're in the middle of a shitstorm.I mean, it was like... I get diabetes, my dad dies, and my husband starts cheating on me, boom, boom, boom.Then there I am, all alone, with four people depending on me.So, I did what I had to. Even if it meant putting my own needs to the side.
Nurse Practitioner Bell: So you've been focusing on others' needs before your own,yet you realize there might be more you could do for yourself.
Lisa: Yeah. I guess we can talk about that a bit. Unless there's something else you wanted to talk about?
Coach: Great! Offering an affirmation about Lisa's efforts to support her family led to Lisa's disclosure of other important information about her situation that will help in collaborating with her on a plan.
Nurse Practitioner Bell: How has it been, having your mom with you?
Coach: Great open-ended question to explore Lisa's experience. Since this is a personal topic for Lisa, you may want to use reflections to show Lisa you're listening, and let her be the one to decide if she wants to share more.
Lisa: I mean, she's fine. Usual mom stuff, I guess.
Nurse Practitioner Bell: It sounds like... maybe not in the best way, your mom wants you to stay healthy.
Coach: Nice! By reflecting what Lisa has told her about her mom, including reframing her mom's efforts, Nurse Practitioner Bell helped Lisa focus on her mom as a potential source of support.
Lisa: That's one way to put it, I guess. She makes these nagging comments about how I should be getting more exercise,eating better, it's tough. But... maybe she's trying to be supportive. In her own, sorta horrible way.
Nurse Practitioner Bell: So your mom can be critical, which is irritating, and at the same time, wants you to stay healthy.
Lisa: Yeah, she can be a real pain, but I don't know,she's lived with diabetes for a while, and she knows what could happen.
Coach: Great double sided reflection! Nurse Practitioner Bell accurately reflected Lisa's feelings while also reflecting Lisa's perception that her mom wants her to be healthy.
Lisa: I do get what you're saying. She's prolly trying to help, whether or not it comes off that way.
Nurse Practitioner Bell: Well, you know your mom better than I do. From what you said, it seems like she's trying to be an ally,especially as you both continue living with your diabetes together.
Lisa: She's really been on a kick, recently. Not sure why she decided to start cranking it to eleven.Honestly... part of the reason I came today was to shut her up.
Nurse Practitioner Bell: That sounds pretty draining.
Lisa: Yeah... She's so... critical of how I live my life.
Lisa: All right, I can definitely see how things have been more difficult recently.Thanks for talking everything through with me. I'm good.
Nurse Practitioner Bell: Okay, let's move on then.
Nurse Practitioner Bell: After all that you've talked about, you still made time to come in today.I think it's great you're putting this much effort into staying healthy.
Lisa: Thanks.
Nurse Practitioner Bell: What do you know about how your diabetes might be affecting how you've been feeling?
Lisa: Well, I know if my blood sugar levels aren't where they're supposed to be then I'm going to feel pretty out of it...I don't remember all the details though. That's why I come see you, right?
Nurse Practitioner Bell: Hopefully not the only reason. And yes, you're right, your blood sugar levels can impact how you feel.
Lisa: See, there you go.
Nurse Practitioner Bell: Can we discuss how diabetes might be affecting your fatigue?
Lisa: Sure... I don't see why not.
Coach: Good! Checking with Lisa before sharing information encourages collaboration and prepares Lisa to be more likely to understand the information.
Nurse Practitioner Bell: So, when you have diabetes and your blood sugars are running high,it means your muscles and organs aren't getting the energy they need and you feel tired.The medications help your body to use the sugar in your blood to give you the energy you need keep you going.
Nurse Practitioner Bell: High blood sugar levels increase the amount of urine you produce so it may explain why you've been needing to use the bathroom at night.
Nurse Practitioner Bell: What do you think of that?
Lisa: Gotcha. I've heard that before, but it's good to hear it again, remind myself what's going on. Thanks.
Coach: Nice job asking for permission, then sharing information in a clear way that Lisa could understand. She was more willing to listen, and likely got a better sense of what Nurse Practitioner Bell was trying to convey.
Nurse Practitioner Bell: I want to make sure the information I shared was clear.So, please tell me what you understood about how diabetes could be affecting your health?
Lisa: Well, if I don't take care of myself and eat well, take meds, exercise or what have you...
Lisa: it can mean my body won't be able to have the energy, uh, blood sugars it needs to keep me going.
Coach: Nice job asking Lisa to share what she understood in a way that suggested any misunderstanding might be due to Nurse Practitioner Bell’s lack of clarity. Because she shared information clearly and without jargon, Lisa understood and could clearly connect the information to her situation.
Lisa: And also, my trips to the bathroom at night could be from my blood sugars being too high.
Nurse Practitioner Bell: You have a solid understanding of how taking care of both yourself and your diabetes can help you stay well.
Lisa: Thanks. I think so too.
Nurse Practitioner Bell: On a scale from zero to ten, how important is it for you to work on managing your diabetes,with zero being not at all important and ten being extremely important?
Coach: Nurse Practitioner Bell did a nice job using the Importance Scale! This gave Lisa a chance to reflect on how important it is to her to make a behavior change and express change talk. It also provides an opportunity for you to respond to her motivation.
Lisa: I'd say... a five.
Nurse Practitioner Bell: What makes you choose a five...
Nurse Practitioner Bell: ...instead of a lower number, like a three?
Lisa: I- I've heard for years about going blind, getting something... amputated. It's hard to think about stuff like that.
Nurse Practitioner Bell: Seems like it's scary to think about health complications like that.
Lisa: Yeah. Definitely scary. You never think it could happen to you, but ...
Lisa: I know this is serious. And I could definitely have some long term health problems from it.
Nurse Practitioner Bell: You're right, it's hard to think about the complications,yet knowing you can avoid them by managing your diabetes is a good thing.
Lisa: Definitely don't want to find myself in here with you holding a hacksaw or something. No, definitely don't want that.
Nurse Practitioner Bell: So let's talk a bit more about how we can keep you healthy.
Lisa: Sounds good.
Nurse Practitioner Bell: Let me go over what we've talked about so far, to make sure we're on the same page.
Lisa: Okay.
Nurse Practitioner Bell: So far I'm hearing you've been busy...
Nurse Practitioner Bell: Looking after your three kids...
Nurse Practitioner Bell: Taking care of your mom...
Nurse Practitioner Bell: Working your job at the diner...
Nurse Practitioner Bell: and you want to try to take better care of your own health because...
Nurse Practitioner Bell: ... you don't want any health complications affecting your quality of life.
Lisa: Yeah. I like my body being in tip top shape- well, at least, in good enough shape!
Coach: Nurse Practitioner Bell did a nice job correctly identifying Lisa's most important motivation! This made her feel heard and intrinsically motivated to make a behavior change.
Lisa: Thanks. I guess it was good I came in today.I'm not sure I would have been able to see all that put together without your help.
Nurse Practitioner Bell: Well, thanks for talking everything through with me so far.Sounds like we're ready to figure out how to make healthy choices work better with your routine.
Coach: Nurse Practitioner Bell chose to move on to making a plan before Lisa had fully explored her motivation.
Lisa: Sounds good to me!
Nurse Practitioner Bell: How do you think you could take steps to better manage your diabetes?
Coach: Nurse Practitioner Bell did a nice job using open ended questions to explore Lisa's ideas, instead of being directive or lecturing her.
Lisa: I know I should look after myself better.
Lisa: But there's a lot working against me, if I'm telling the truth.It's hard to find time to take my medication, and even harder to eat healthy meals.Don't even get me started on exercise, that's a whole 'nother ordeal.Thinking about it all at once is... kind of overwhelming.
Nurse Practitioner Bell: Tell me a little more about your experience with exercising.
Lisa: Oh, that's the big one. I- I know how important it is.You don't need to go pulling out the pamphlets and all, I've seen it all before.I just- don't have the energy. By the time I get home, all I want to do is be with my kids,sit with my mom, and catch my breath.Except most of the time I can't even do that, because there's always something to do there, too.
Nurse Practitioner Bell: So when you come home, it's important to spend time relaxing with your mom and your kids.
Lisa: Yeah. After a long day, there's no part of me that wants to go run a marathon.
Nurse Practitioner Bell: It seems like you enjoy being with your family. How do you feel about exercising together?
Lisa: When we've committed to giving it a try, it's been fun.Going to the park, or even just walking around the neighborhood.
Coach: Nurse Practitioner Bell’s reflection and open-ended question led Lisa to think about benefits of exercising with her family.
Nurse Practitioner Bell: You've exercised as a family before, which shows you've made important healthy choices in the past.
Lisa: Yeah, we've put effort into staying healthy before.
Lisa: I could probably put it on the family calendar when the timing works,and whoever's around could join me. Could be fun, actually.
Nurse Practitioner Bell: That's a great idea to try and get more exercise.
Lisa: I'd still like to talk a little more about... the things working against me, if that's okay.
Nurse Practitioner Bell: Absolutely.
Nurse Practitioner Bell: What was it like when you tried eating healthy foods?
Lisa: I mean, I bought veggies, made more balanced meals when I could.But the kids weren't too excited about it,they were always asking for what they were used to, pizza, burgers, the like.I don't hold that against them, that's the kind of thing I eat myself in the middle of a shift,when I even have time to eat. Anyway... by the time I had a night free to cook,a lot of the food had gone bad. I decided it just wasn't worth it.
Coach: By asking an open-ended question about Lisa's experience with healthy eating, Nurse Practitioner Bell showed her she heard about the positive steps she had taken in the past.
Nurse Practitioner Bell: So your kids were resistant to healthy meals, but you still tried for the sake of your health.
Lisa: Yeah. I gave it a shot with them. It's easier when I'm eating without my kids.I might be able to try eating healthier in the middle of a shift at work.I see how much butter goes into our grilled cheese...
Coach: This double sided reflection included an affirmation about her interest in eating healthy, which led to more elaboration and some change talk.
Nurse Practitioner Bell: So even if making healthy dinners is out of the question, you might consider eating a healthy lunch.
Lisa: Yeah. I mean...
Lisa: It's probably not as big a deal as I think it is. I can be okay eating salads at work.And if I get bored of them, maybe I can just bring a baggie of carrots, or nuts, or something.
Nurse Practitioner Bell: Healthy snacks are a great way to get a routine started. And every step counts.
Coach: Nurse Practitioner Bell’s supportiveness helped Lisa feel empowered and identified another strategy that she might try.
Nurse Practitioner Bell: Sounds like you're feeling better about eating more healthy meals.
Lisa: Thanks. I'd still like to talk a little more about my meds, if that's okay.
Nurse Practitioner Bell: So you want to focus more on taking your medication.
Lisa: I'm so busy keeping track of each of my kids' schedules that- I guess I lose track of my own.
Coach: Reflecting Lisa's desire to work on taking her meds led her to elaborate on her feelings.
Nurse Practitioner Bell: It sounds like your kids' schedules are pretty complicated,more than your medication schedule, and you stay on top of them well.
Lisa: That's true.
Lisa: I- it might be a little silly, but... I print out this calendar, and color code it for each kid.They got to choose the colors, which makes them happy. And then I know what's going on, you know?
Coach: Nurse Practitioner Bell’s reflection contains an affirmation about Lisa's ability to manage her kids' schedules, helping her feel empowered.
Nurse Practitioner Bell: It sounds like you use that calendar to keep track of a lot of info.
Lisa: With three kids, I do what I have to! But maybe...starting next week, I could try putting something on the calendar, as a reminder to myself.I'd want to use some kind of a codeword, so the kids don't worry too much about me.
Nurse Practitioner Bell: So you really don't want your kids to know about your diabetes.
Lisa: I mean... maybe it's better if they do know.I worry about it upsetting them, but- they're tough, you know? They can handle it.
Coach: Affirming Lisa's strength led her to identify a potential solution and a willingness to take specific steps toward change.
Nurse Practitioner Bell: That sounds like a great plan to think about your medication.
Lisa: I'm actually feeling... pretty good about everything! Thanks. I'm good to move on.
Nurse Practitioner Bell: I'm glad you're feeling better about everything.
Lisa: Same here. Just gotta stay focused and keep in mind what's important to me.
Nurse Practitioner Bell: Like wanting to keep yourself as healthy as possible.
Lisa: Exactly.
Lisa: I like all my arms and legs, thank you very much!
Nurse Practitioner Bell: Makes sense.
Coach: Nurse Practitioner Bell did a nice job correctly identifying Lisa's most important motivation! This made her feel heard and intrinsically motivated to make a behavior change.
Lisa: Y'know, I thought you were going to come in and give me a big ol' lecture today.I'm glad you're not that kind of person.
Nurse Practitioner Bell: Thanks. You know more about what works well for your family than I ever will.
Nurse Practitioner Bell: I'd like to work together and set a goal that you can work toward. How's that sound?
Lisa: Okay, that sounds good. What kind of goal?
Nurse Practitioner Bell: One that's clearly defined, achievable, and beneficial to your health.
Lisa: Understood.
Nurse Practitioner Bell: To build on what we were just talking about, in regard to your diabetes management,what would be a specific, realistic goal over the next three months?
Lisa: Well...
Lisa: I might try to check in with the kids about going for family walks, see what they think...
Lisa: I could consider eating healthier lunches, either salads, or some healthy snacks I bring myself...
Lisa: The most important thing for me would be, starting with the new calendar next week,I could put my med schedule up in my own color, and really make an effort to take my medication.
Nurse Practitioner Bell: That makes sense.
Nurse Practitioner Bell: No change is too small here. Any change you make is a step toward being healthier.
Lisa: That's good to keep in mind, and less pressure is a bit of a weight off my shoulders... thanks.
Nurse Practitioner Bell: When would be a good time for me to check in on how things are going?Ha. I don't know, my schedule is all over the place. A call might be a little tricky. Any other options?
Nurse Practitioner Bell: You're welcome to send a secure text message to update me on the plan.
Lisa: Okay, I should be able to shoot you a quick text next week.
Nurse Practitioner Bell: Sounds good.
Coach: Great idea to ask about preferences for follow-up to the plan. It increases the likelihood of follow through and provides an opportunity for subsequent problem-solving.
Nurse Practitioner Bell: On a scale from zero to ten, with zero being not at all confident and ten being extremely confident, how confident do you feel about sticking to your goal?
Lisa: I would say... a seven. Out of ten.
Coach: ssessing confidence using the scale allowed you to get a sense of where Lisa: is in her confidence and will help Nurse Practitioner Bell to further explore both her feelings of empowerment as well as her barriers to success.
Nurse Practitioner Bell: What makes you say a seven instead of a lower number like a five?
Lisa: I'm pretty disciplined, I know how to push myself and stick to a plan. Comes from my years in the service.
Coach: Nice! By asking what contributed to her rating versus a lower number, Nurse Practitioner Bell helped Lisa focus on positive attributes and strengths that provide bolster empowerment, while also providing you with opportunities for affirmation.
Lisa: And... I'm good at taking care of people, keeping track of my kids' schedules. I can take care of myself too.
Nurse Practitioner Bell: Who do you have to help you with managing your diabetes?
Lisa: No one, really. Just me.
Nurse Practitioner Bell: How would you feel about including your family more in that process?
Lisa: I mean... I don't want to burden them. But I see what you're saying.Maybe I could sit down with my mom, see if she'd be willing to help set the kids up with cereal in the morning,so I could be sure to have time to take my pills.
Nurse Practitioner Bell: So even a little more time could make a big difference.
Lisa: It's worth a shot.
Coach: Great idea! Asking open-ended questions about sources of support provides an opportunity to increase openness to an action plan.
Nurse Practitioner Bell: You do an impressive job of taking care of people, and I'm sure you'll be able to look after your health too.
Lisa: Thanks. I hope so.
Nurse Practitioner Bell: What would it take to make you more confident, closer to an eight or a nine?
Lisa: I don't know, with me spread so thin... there's just a certain amount that I have to accept I can't do.But... I guess I'd be more confident if I had some time in the morning, when I'm getting the kids ready for school.
Nurse Practitioner Bell: Ah, I can see why that would be a challenge. What could you do to address that barrier?
Lisa: Hmm... maybe I could set my alarm ten minutes earlier than I do now and really try not to hit the snooze button,so I can take my pills before I have to wake my kids up.
Nurse Practitioner Bell: That seems like a good way to stay on top of taking your medication.
Lisa: Yeah... cause once I'm fighting with my oldest to get herself out of bed, that's the rest of my morning, gone!
Coach: Good choice. By asking what will help her be more confident, Nurse Practitioner Bell helped her identify a barrier and a solution to overcome the barrier!
Nurse Practitioner Bell: So, what else might get in the way of you meeting your goal of remembering to take your diabetes medication?
Lisa: Hmm... I guess at the end of the day I'm already tired, and I still have so much to do,cooking dinner, helping the kids with their homework, picking out what clothes to wear,you know how little girls can be about their outfits!
Nurse Practitioner Bell: I do! So any ideas about how to address that busy time?
Lisa: Well... maybe I can try to ask my oldest to help remind me to take my evening dose.For all her teenager ways, Rita can be pretty responsible!And it would be good to have something that she's doing to help me, so we're...on the same team sometimes. Not always at each other's throats.
Nurse Practitioner Bell: Sure. That sounds like it could help. So how might that happen?
Lisa: I can sit down with and chat tonight, when she gets home from practice.
Nurse Practitioner Bell: Sounds like a plan.
Coach: Good! After Lisa felt motivated to make a change, Nurse Practitioner Bell asked about challenges she might face and how she might prepare for them.
Nurse Practitioner Bell: Would it be okay if I go over what we talked about?
Lisa: Yup. I gotta get going.
Nurse Practitioner Bell: You're going to put your medication schedule on your family calendar...
Nurse Practitioner Bell: You'll try to set your alarm a little earlier, to help you take your medication in the mornings...
Nurse Practitioner Bell: You'll chat with your mom about helping with your kids' breakfast...
Lisa: You'll try to get your daughter to help remind you to take your evening pills...
Nurse Practitioner Bell: You're going to try going on family walks a couple times a week...
Nurse Practitioner Bell: You're going to see if you can eat a more healthy lunch while you're at work...
Nurse Practitioner Bell: And you'll check your calendar and let me know when it would be a good time for a follow up appointment.How's that sound?
Lisa: Sounds good to me.
Nurse Practitioner Bell: Thanks so much for talking, Lisa. I look forward to hearing from you next week.
Lisa: All right. I'll text you an update then.
Coach: Lisa left her appointment with a plan to take her medication more regularly by putting it on her family calendar. Also, she would like to try exercising in a way that involves her whole family and eat salads or healthy snacks for lunch at work. Lisa felt empowered by her visit with Nurse Practitioner Bell, and followed through on her plan to better manage her diabetes. During Lisa's next appointment, her A1C levels had improved, and she said she was feeling a little less tired in general.
Nurse Practitioner Bell: Hi Ms. Crane, it's good to see you again.
Lisa: Yeah, same. And Lisa's fine. Can we get started? I got a lot on my plate today.
Nurse Practitioner Bell: Sure thing.
Nurse Practitioner Bell: It's important to check in with us every few months, for your health. What kept you from the last one?
Lisa: I- I had a lot going on. Not sure what, the days all kind of... blend together.
Nurse Practitioner Bell: I can understand that. Well, you're here now.
Coach: Nurse Practitioner Bell’s question, although well-intentioned, came off as more of an admonishment. An effective open-ended question's message is neutral and avoids judgement.
Lisa: Can we please get going?
Nurse Practitioner Bell: Okay.
Lisa: Sorry, if I don't pick up my kid before my friend leaves for work,he's gonna get up to all sorts of mischief with those friends of his.
Nurse Practitioner Bell: You know, I don't think I've asked before, what branch did you serve with?
Coach: Nurse Practitioner Bell did a nice job asking a question about Lisa's service. This allows you to build a personal connection by expressing respect for her service.Lisa: Uh, I was a Marine from '80 to '84 and then I served in the coast guard...
Lisa: I'm sorry. I really want to just get started.
Nurse Practitioner Bell: All right. No problem.
Nurse Practitioner Bell: All right, let's get started.
Nurse Practitioner Bell: Today, we should focus on how you've been managing your diabetes.
Coach: By setting the agenda for the visit with Lisa, Nurse Practitioner Bell pushed her into a discussion she may not be interested in having. Asking an open-ended question about her agenda would give her some control and help Nurse Practitioner Bell learn about the issues she cares about.
Lisa: Look. I'm fine. Okay?
Nurse Practitioner Bell: It's important to figure out how we can use today to help you.
Lisa: Yeah, yeah. I know... you're just trying to help.
Nurse Practitioner Bell: Exactly.
Lisa: Look, I don't even know if I want to be here. It's hard for me to think about this with so much on my mind.And now you're probably going to start suggesting ways to make it all better with "what if" scenarios...
Lisa: It's just... tiring. So it's hard to keep up with my meds, and the like.
Nurse Practitioner Bell: Maybe you could be eating healthier?
Lisa: What's that supposed to mean?
Nurse Practitioner Bell: I'm just trying to understand what's been making you tired.
Lisa: Well, you coulda just said that.
Nurse Practitioner Bell: Right. Sorry.
Lisa: Well...
Coach: This closed-ended question made an assumption about Lisa's eating habits. A neutral open-ended question would allow Nurse Practitioner Bell to explore Lisa's perceptions and ideas about contributions to her fatigue.
Lisa: I mean... for the past... I don't know how long, I've had so much on my mind.My kids always need to be driven from place to place, my mom is always critical of how I'm living my life,and I'm working long hours at the diner... which throws me out of whack.
Nurse Practitioner Bell: Sounds like you have a lot going on - it's understandable that's impacting both you and your diabetes.
Lisa: Right.
Nurse Practitioner Bell: Can we can explore those areas of your life a bit more, and see how they might be connected to your health?
Lisa: Sure. Why not.
Nurse Practitioner Bell: I think the best thing you can do right now is stay on top of your diabetes, which will make you feel less tired.Lisa: Maybe, but I think my feelings of tiredness are mostly connected to... my tiring life.
Coach: While Nurse Practitioner Bell may want to prescribe the best course of action for Lisa, it's important to ask Lisa about her perceptions, ideas and feelings about her tiredness.
Nurse Practitioner Bell: Sorry to hear about how hard you've been working.Lisa: When I was in the marines, I would work much longer hourshauling around a lot more weight than three burgers and a steak.Even riding the boat was a bigger deal a lot of the time.
Nurse Practitioner Bell: I see. So, the work itself is not that difficult for you.
Lisa: That's right. It's everything... all of it.
Coach: Though Nurse Practitioner Bell’s intention may have been to express compassion, the use of "sorry" was experienced as patronizing. Instead, try using reflections that seek to understand and give Lisa a chance to elaborate, like, "You have been working long hours."
Nurse Practitioner Bell: I think this job might be making it difficult for you to keep up with other things in your life.Are you looking for other job opportunities?Coach: Though Nurse Practitioner Bell may have thought she was helping Lisa, she felt your suggestion was off-target. Try using reflections and open-ended questions to explore her ideas/feelings to deepen understanding and foster collaboration.
Lisa: Well thanks, miss works-at-a-hospital-and-makes-twice-my-income. I'll take that under advisement.
Nurse Practitioner Bell: That's not what I meant-I don't really care what you meant. Okay?
Lisa: You know what? I'm kinda tired of talking about my job. Let's just drop it.
Nurse Practitioner Bell: Uh, okay. You sure?
Lisa: Yes. I'm sure.
Nurse Practitioner Bell: So your kids are keeping you busy... that seems normal for a parent. How can you better manage that?
Lisa: It's not easy... I don't think you get how hard it is.
Nurse Practitioner Bell: Okay. Sorry.
Coach: Nurse Practitioner Bell’s effort to understand her is admirable, but her reflection was off target and felt dismissive to Lisa. Instead, she can consider validating Lisa’s points of stress to help her feel understood and more willing to collaborate on a course of action.
Nurse Practitioner Bell: As far as I know, the best way you can be there for your kids is by looking after yourself.
Coach: Encouraging Lisa to focus on her own needs is admirable, though she finds Nurse Practitioner Bell’s advice dismissive. Instead, consider reflecting and validating her feelings to help Lisa feel understood and perhaps more willing to explore and collaborate on possible strategies and solutions.
Lisa: You think I don't know that? Doesn't change the number of hours in a day, or the number of places my-- forget it. Do you even have kids?
Nurse Practitioner Bell: I- I don't.Exactly.Lisa: I- You know what? Let's stop talking about my kids. If I'm being real, it's putting me a little on edge.
Nurse Practitioner Bell: Uh, okay. You sure?Lisa: Yes. I'm sure.
Lisa: Honestly... I'm kind of tired of hearing you talk to me like that. What else do we have to talk about?
Coach: Nurse Practitioner Bell’s approach has led to too much discord for Lisa to feel open to discussing how her tiredness connects to her diabetes.
Nurse Practitioner Bell: It seems like your kids have been especially tiring lately, maybe more than usual.
Coach: Great! By reflecting Lisa's tiredness, Nurse Practitioner Bell showed her she was earnestly listening and trying to understand her perspective.
Lisa: Maybe? I don't really even have time to think about what things used to be like.Farthest ahead I look is what I have coming up in a few hours,and without a calendar I have no idea what happened last week.
Nurse Practitioner Bell: I hear you're busy with your kids. How are you taking time to care for yourself, look after your own health?
Lisa: I- I don't know. I got a babysitter... last month, and took an aerobics class a friend was teaching,but- It's been a little while. There's just not enough time, with everything I have to do for my kids.
Coach: Great choice! You used a reflection about how busy Lisa is and followed it with an open-ended question that tapped into her motivation for self-care. Note how this choice also opened the door for Lisa to bring up other concerns.
Lisa: I guess... sometimes I can get lost in taking care of my kids instead of taking care of myself.
Nurse Practitioner Bell: That seems pretty understandable.
Lisa: But that's just one part of it, you know?
Nurse Practitioner Bell: So there are some other parts of your life you'd like to discuss.
Lisa: Well... yeah, I guess.
Coach: Starting a question with "why" may add an unwanted judgmental tone. Also, by suggesting a specific solution, Nurse Practitioner Bell missed an opportunity to empower Lisa to explore her own ideas about remembering to take her medication.
Nurse Practitioner Bell: Your mom has a point, you should be looking after yourself.
Lisa: Really? You're taking her side?
Nurse Practitioner Bell: I'm not taking anyone's side. I'm just saying she's right, taking care of your health is important.
Lisa: Gotcha.
Coach: Nurse Practitioner Bell’s effort to help Lisa focus on her own needs is admirable, though instead of telling Lisa what she 'should do,' consider reflecting and validating her feelings and using questions to explore HER ideas for addressing her needs.
Nurse Practitioner Bell: It sounds like... maybe not in the best way, your mom wants you to stay healthy.
Coach: Nice! By reflecting what Lisa has told her about her mom, including reframing her mom's efforts, Nurse Practitioner Bell helped Lisa focus on her mom as a potential source of support.
Lisa: That's one way to put it, I guess. She makes these nagging comments about how I should be getting more exercise,eating better, it's tough. But... maybe she's trying to be supportive. In her own, sorta horrible way.
Nurse Practitioner Bell: So your mom can be critical, which is irritating, and at the same time, wants you to stay healthy.Lisa: Yeah, she can be a real pain, but I don't know,she's lived with diabetes for a while, and she knows what could happen.
Coach: Great double sided reflection! Nurse Practitioner Bell accurately reflected Lisa's feelings while also reflecting
Lisa's perception that her mom wants her to be healthy.
Lisa: I do get what you're saying. She's prolly trying to help, whether or not it comes off that way.
Nurse Practitioner Bell: Well, you know your mom better than I do. From what you said, it seems like she's trying to be an ally,especially as you both continue living with your diabetes together.
Lisa: She's really been on a kick, recently. Not sure why she decided to start cranking it to eleven.Honestly... part of the reason I came today was to shut her up.
Nurse Practitioner Bell: That sounds pretty draining.Lisa: Yeah... She's so... critical of how I live my life.
Lisa: All right, I can definitely see how things have been more difficult recently.Thanks for talking everything through with me. I'm good.Nurse Practitioner Bell: Okay, let's move on then.
Nurse Practitioner Bell: So, these feelings of exhaustion could be connected to high blood sugar levels,which are caused by both lack of enough insulin or insulin resistance.That means your body isn't responding to the insulin, and can't get the blood sugar into your cells.In addition, over time, high blood sugar levels cause vascular diseasein both large and small vessels which makes it harder for blood to flow.
Nurse Practitioner Bell: What do you think of that?Lisa: Well, I feel like you just went "all doctor" on me, which is never easy to get used to.But... I get what you're saying.
Coach: When Nurse Practitioner Bell shared information with too much jargon, especially without asking for permission first, Lisa had a harder time understanding and felt confused about how it related to her health. Using plain language can help foster both understanding and collaboration.
Nurse Practitioner Bell: I think there's more you can learn about how your diabetes is affecting your health.
Lisa: I'm fine. Thanks.
Nurse Practitioner Bell: It's just- based on the choices you've been making recently, I'm not sure that's true.
Lisa: You know what? I do have a solid understanding about what's going on. It's just... hard to do something about it.
Coach: Telling Lisa she had more to learn about her diabetes came off as condescending and disempowering. Nurse Practitioner Bell can consider asking more questions about her understanding and about her ideas for improving self-care to build motivation and confidence to make a change.
Nurse Practitioner Bell: Seems like we're ready to move on and talk a bit more about how diabetes is affecting your life.
Lisa: Yeah, gotta figure out some way to keep up with all this.
Nurse Practitioner Bell: We should chat a bit more about how you plan on managing your diabetes.
Coach: When Nurse Practitioner Bell tells Lisa what to talk about instead of asking her, she is less likely to be ready to collaborate. Also, Nurse Practitioner Bell moved on to making a plan before Lisa had fully explored her motivation.
Lisa: Sure.
Nurse Practitioner Bell: I have some ideas about how you can better manage your diabetes.
Lisa: Oh yeah? Well, I have some thoughts too.
Nurse Practitioner Bell: Oh, okay. Share away.
Coach: Even if she thinks she knows what's best for Lisa, it's often better to use reflections and ask questions to let your patient feel in control of their own solutions. Lisa knows her situation better than anyone else! Asking Lisa to 'fire away' and share her ideas was a nice recovery.
Lisa: So, recently I've been thinking about...
Lisa: How much my family needs me. Don't know what they'd do without me, really.
Lisa: I know I should look after myself better.
Lisa: But there's a lot working against me, if I'm telling the truth.It's hard to find time to take my medication, and even harder to eat healthy meals.Don't even get me started on exercise, that's a whole 'nother ordeal.Thinking about it all at once is... kind of overwhelming.
Nurse Practitioner Bell: A small change in your diet can make a big difference in your health.
Lisa: Right. I know. I've tried eating healthier, but with the kids,and my long hours at the diner- it just wasn't worth the headache.
Coach: Impressing on Lisa the impact of a behavior change like improving her diet isn't the best way to motivate her.
Nurse Practitioner Bell can try using more open-ended questions and reflections to collaborate with Lisa.
Nurse Practitioner Bell: It sounds like it's going to be pretty tricky to eat more healthy foods.
Lisa: Yeah. Like I said, when I get home, there's not a lot of time left to cook.When I do have time to eat at work, I'm always eating... "comfort food,"which I really do enjoy even if I know it's not the best for me.
Coach: Reflecting her sustain talk reinforces to Lisa how difficult change could be. If Nurse Practitioner Bell instead brainstormed with Lisa on ways she can eat healthier, she can redirect focus from the negative to the positive.
Nurse Practitioner Bell: On one hand, you could eat healthier options at work. On the other hand, you might not have time.
Lisa: Right. That's definitely a hurdle. Not sure how I'm going to be able to overcome it...
Coach: Reflecting the change talk first and ending with the sustain talk led LIsa to continue to express sustain talk. Nurse Practitioner Bell can try ordering double-sided reflections with the change talk second to elicit more change talk.
Lisa: I- I'll just try to eat healthier by myself.
Nurse Practitioner Bell: I'm happy to keep talking-Nah. I'm okay. Thanks.
Lisa: Let's just talk about something else.
Nurse Practitioner Bell: Uh... okay.
Nurse Practitioner Bell: There was a study published recently about how important exercise is, especially for people with diabetes.
Lisa: Well, I don't know about... "studies" or anything,but I do know it's hard to exercise when I get home. All I want to do is spend time with my kids.
Coach: While she may mean well in providing Lisa with that information, Lisa felt as if Nurse Practitioner Bell was pushing a change onto her. Next time she can ask for permission to share the information and she may be more receptive.
Nurse Practitioner Bell: Getting exercise as a family could make a big difference, for everyone's health.
Lisa: Right. I know that.
Coach: Telling Lisa that exercise could make a difference in her family's health misses an opportunity to be more collaborative. Nurse Practitioner Bell can try using more open-ended questions and reflections to empower Lisa and help her to come up with her own ideas for change.
Nurse Practitioner Bell: What if you took a yoga class as a family? I have friends who do that.
Coach: Though trying to mediate between Lisa and her mom might feel helpful, it's not Nurse Practitioner Bell’s place to resolve conflict between them and Lisa felt like she crossed a line. Also, Nurse Practitioner Bell can try keeping in mind that Lisa mentioned earlier that she considers "what if" scenarios as ways to push solutions onto her.
Lisa: I- I'll just find a way to get exercise myself, okay?
Nurse Practitioner Bell: Okay, sure.
Lisa: And... I think I'd rather figure the rest of this out for myself.
Nurse Practitioner Bell: Are you sure?
Lisa: Yeah. I'm sure.
Nurse Practitioner Bell: You know I'm happy to hop on a call if you decide you want to talk things through more.
Lisa: Yep. I know. I think I'll be fine.Just gotta keep in mind what's important to me.
Nurse Practitioner Bell: Like being there when your kids get older.
Lisa: sure. I guess that'll help me.
Nurse Practitioner Bell: Tell me your goal for the next few months. It should be specific and realistic.
Lisa: Pfft... uh, "yes ma'am".
Lisa: Well.
Coach: Asking Lisa to set a specific and realistic goal at this point is somewhat premature and directive. It would be better and more collaborative to ask permission to focus on a goal, which supports her autonomy and may increase buy-in.
Lisa: The most important thing is figuring out a way to take my meds better.
Nurse Practitioner Bell: That makes sense.
Nurse Practitioner Bell: I'm sure if you try really hard, you'll be able to take care of yourself, just like you take care of your family.
Lisa: Sure.
Coach: Using vague encouraging language makes Lisa feel like Nurse Practitioner Bell doesn’t understand or care about her as an individual. Next time, she can try being more specific when making an affirmation.
Nurse Practitioner Bell: I think you're going to be able to stick with your goal this time around.Lisa: I'm gonna try.
Coach: Nurse Practitioner Bell may be aiming to encourage Lisa, though the statement has a patronizing tone. Instead, she can consider affirming her past efforts and interest in self-care to help Lisa feel empowered, with less risk of feeling
Nurse Practitioner Bell: Would it be okay if I go over what we talked about?
Lisa: Sure, go right ahead.
Nurse Practitioner Bell: You'll figure out a plan to take your medication that works for you...
Nurse Practitioner Bell: You're going to keep thinking about a plan to get some more exercise...
Nurse Practitioner Bell: You're going to keep thinking about a plan to have a bit of a healthier diet...
Nurse Practitioner Bell: And hopefully I'll see you at your next appointment. Right?
Lisa: ... Sure. Thanks.
Nurse Practitioner Bell: Happy to help.
Coach: Lisa left her appointment with an intention to figure out how to be better at taking her medication. She felt frustrated by her conversation with Nurse Practitioner Bell, and missed her next appointment. When she showed up a few months later, her A1C levels had gotten higher, she did not report any changes in behavior, and she said she was feeling even more tired since her last visit.
Gregory Mitchell is a 67-year-old veteran with cardiovascular disease who had an angioplasty after a myocardial infarction. His doctor had discussed with him smoking, alcohol, diet, and exercise.
You’ll take on the role of Nurse Clarke, a VA RN care manager, and speak with Gregory at a follow-up appointment three weeks after the procedure.
CONVERSATION GOALS
Explore Gregory’s perspective on his cardiovascular health and encourage him to discuss what he wants to work on.
Use Reflective Listening to acknowledge Gregory’s concerns about risks to his health.
Use a Shared Decision Making approach to collaborate with Gregory about cardiac rehab programs and other options to improve his health.
Assist Gregory, if he’s ready, in setting a specific and attainable goal to address his barriers.
Nurse Clarke: Good to see you again, Mr. Mitchell.
Gregory: Call me Gregory... And, yeah, good to see you, too, under... better circumstances.
Nurse Clarke: You're looking good, since the procedure!
Gregory: Thanks. Been a whirlwind of a month, that's for sure.Come a long way since the last time I was here, when I was... not in great shape.
Nurse Clarke: Sounds like it was a little scary for you, last time you were here.
Gregory: I know you folks are professionals and all, but when you all rushed me in...I wasn't sure what was happening to me. I remember the doctor saying she had to put stents in...to keep me from having a lot more damage to my heart. Didn't expect to hear that when I woke up that morning!
Coach: Great! This empathic reflection built rapport and spurred Gregory to elaborate.
Nurse Clarke: It can certainly be disorienting coming in here,which is why I was so happy when Dr. Cantwell told me today that you've been doing a lot better.
Gregory: Hasn't been easy, that's for sure! But neither was being a load toad in Vietnam,or hauling cargo after I got back. You do what you gotta, I guess.
Nurse Clarke: That's a good way to look at things.
Coach: Great job! Your reflection normalized Gregory's fears and acknowledged that his health has improved. As a result, Gregory feels more comfortable in this conversation.
Nurse Clarke: How have things been at home since your procedure?
Gregory: Oh, you know. I'm doing fine, but my wife is always bugging me about this or that.
Nurse Clarke: And what's that like?
Gregory: I mean, she gets on my case about the same thing, over and over again.
Coach: Good job! By asking an open-ended question about Gregory's home life, it shows that you care about his "whole health," not just his heart condition.
Nurse Clarke: I hear you, it feels like your wife is looking over your shoulderwhen you're the one in charge of managing your recovery, and that's frustrating.
Gregory: Exactly! I got it covered, and she's worried all the time. She's a good woman.But after all this time, she really knows how to piss me off!
Nurse Clarke: So you two are pretty close?
Gregory: I know exactly what she's thinking, and she knows exactly what I'm thinking... it's that kind of thing.
Coach: Nice! You responded with a complex reflection to show you're interested in Gregory's perspective and how he feels, which encouraged him to open up about his wife with you.
Nurse Clarke: What branch are you with, Gregory?
Gregory: Air Force, former airman, first class.
Nurse Clarke: My uncle served in the Air Force. Good people there.
Gregory: You know it. The best.
Coach: Great! You built rapport by asking Gregory about his service.
Nurse Clarke: Well let's get started. What do you know about why Dr. Cantwell wanted us to talk today?
Gregory: Honestly?... I'm not sure why Dr. Cantwell sent me your way... I've been feeling pretty good since the procedure,back to living the way I want, for the most part. Pretty fast recovery for someone at my age, huh!
Nurse Clarke: Glad to hear you're feeling better.What do you think you need in order to keep your recovery going in the right direction?
Gregory: I dunno... I guess if you've got some recommendations, I'll hear you out, but...I think it's just a matter of time before I'm feeling like myself again.
Nurse Clarke: It's great you're feeling better, and you're open to talking about keeping your heart strong.
Coach: Great job! Gregory's attention shifted to planning and collaboration as he considered your open-ended question.
Coach: Good! Gregory's attention shifted to planning and collaboration as he considered your open-ended question. Though Gregory would've felt more comfortable if you had first acknowledged his fears and struggles from his past procedure.
Gregory: Sure. Can't hurt to talk. But... y'know, like I said, I'm just healing up as time goes on.
Nurse Clarke: What have you been doing to strengthen your cardiovascular health the last three weeks?
Gregory: Well, when I left the hospital, the plan was to get exercise when I could,whether by walking with my wife or playing golf with my buddies.They also talked to me about giving up smoking, trying to eat less fried food, and drinking less.
Nurse Clarke: And how's all that going?
Gregory: Okay, I suppose. I haven't had a cigarette for... 23 days now,and I've been taking all my meds, the blood pressure ones and the new ones to protect my heart.So I've been starting to... live the way I like to live. Feeling pretty good about it.
Nurse Clarke: Staying smoke free is a very important way to improve your cardiovascular health.
Gregory: Exactly. And as time goes on, I'm just going to keep getting stronger.
Coach: Great job! You asked an open-ended question that encouraged Gregory to share the positive changes he made for his cardiovascular health.
Nurse Clarke: It's great that you've stayed smoke free.It's the most important way to keep your heart healthy and prevent another heart attack.And it's great that you've been consistently taking your meds.
Gregory: Yeah, they told me the medication would help keep the stents open, so... been takin' 'em.And I know how important it is for me to stay smoke-free. But also, I'm just healing up over time.
Coach: By affirming Gregory's specific efforts to live a healthier life and follow through with medications, you let him know that you're aware of the progress he's making.
Nurse Clarke: Your effort to stay smoke free and take your medication... these are all impressive accomplishments.Now it's about building on the good work you've already done.
Gregory: I guess... huh.
Nurse Clarke: What?
Coach: Your affirmation helped Gregory feel that his efforts matter, though be careful about making assumptions about his follow-through with other behaviors. Consider asking about these.
Gregory: I mean... MAYBE the stuff I've been doing so far has made a difference.But now that I'm feeling better, that might change what I want to do next.
Nurse Clarke: How are you feeling about the progress you've made so far?
Coach: Great! This open-ended question tapped into Gregory's experience in a non-judgmental way, which spurred him to respond genuinely and share his feelings.
Nurse Clarke: I... I don't know. I'm glad I'm getting better. It's just- it's a lot of changes.
Gregory: What do you mean?
Nurse Clarke: All this pressure to get more exercise, the idea of never smoking again,drinkin' less, giving up the food I've enjoyed my whole life...
Gregory: I know it's what I gotta do, but... it's tough is all.
Nurse Clarke: So the steps you've taken to look after yourself are challenging,yet you also understand that this is the best way to stay healthy.
Gregory: Yup. I know what I'm supposed to be doing for my health.But I also know how I want to be living my life, the same way I've always lived it.
Coach: Great! You used a double-sided reflection to show you are hearing Gregory's concerns while also reflecting his interest in protecting his heart.
Nurse Clarke: It's good you know what to do to protect your health.
Gregory: Yeah, I think I have a good sense of how I should be looking after myself.Just have to figure out what exactly I want to do about it.
Coach: By using an affirmation, you reassured Gregory that he is taking the right steps.
Nurse Clarke: On a scale from zero to ten,how important is it for you to make some of the recommended changes to keep your heart strong,with zero being not at all important and ten being the most important?
Gregory: I guess I'd have to say... a five? Could go either way, honestly.
Coach: Using an importance scale helps you and Gregory understand how motivated he is in making changes for his health and sets you up to explore what drives that motivation.
Nurse Clarke: Why did you say a five, rather than a lower number, like a three?
Gregory: Why higher than a 3... you mean, why is this important?
Nurse Clarke: Yeah, exactly.
Gregory: Well... I've been doing a lot of thinking since the procedure, you know. About my health. My life.I feel winded when I play catch, or lift a box at work. I'm not sure I'm okay with that.
Coach: Good job! By comparing Gregory's answer to a lower number that he could have picked, you helped Gregory reflect on what is driving his motivation and you elicited change talk.
Nurse Clarke: What would make your rating of importance higher than a 5, say a 6 or 7?
Gregory: I dunno. Something else would have to go wrong. Or there'd have to be a really good reason to take care of myself.
Coach: Great! By asking what would make importance higher you spurred Gregory to think about reasons for staying healthy, creating an opening for further exploration.
Nurse Clarke: How would staying healthy make a difference in your life?
Gregory: It's probably too late for me to play major league, huh. Probably.
Gregory: Well, I've already done a lot in my life...
Coach: Great open-ended question to further explore core elements of motivation !
Gregory: These days- what I'm really thinking about is my dad, and my brother.One time, growing up, a car started rolling down a hill where we were parked, and they ran over, caught it,pushed it back up until it was safe, and the driver came back. Hm.Didn't stop their hearts giving out when they got older. I-I don't want to end up like that.
Nurse Clarke: It sounds like your dad and brother have been on your mind recently.
Gregory: Yeah. Yeah, they were tough. Broad shoulders, big hearts. Maybe too big. They died before their time for sure.
Nurse Clarke: How did they die?
Gregory: Heart disease, same thing I got. "The Mitchell heart", I guess. It's... hard to think about them.
Coach: Good! Your use of an accurate reflection stimulated Gregory to share important information about his family and his beliefs.
Nurse Clarke: So you want to have a long, full life. The kind you wish your dad and brother could have had.
Gregory: Yeah. But it's confusing, you know? They both had a lot of love.And my dad kinda just accepted it and died the way he lived, but my brother fought it.He tried hard to get more exercise, eat better, all the stuff you folks tell me.And in the end, he ended up the same damn way.
Nurse Clarke: It sounds like your brother put in a lot of effort to look after himself.
Gregory: I guess. Didn't do him any good... but who knows. Maybe it'll go differently with me.
Coach: Good choice! This accurate complex reflection captured both Gregory's feelings and his change talk and it prompted him to confirm it and share more.
Nurse Clarke: Any step forward is a step forward.
Gregory: Seems like a pretty low standard, no?
Nurse Clarke: I have plenty of patients who aren't able to quit and stay quit for as long as three weeks.Kicking a habit like tobacco use isn't easy, it's an impressive accomplishment.
Gregory: Maybe it is.
Coach: Nice work! Affirming Gregory's specific efforts to live a healthier life helps him understand that you know he's trying to make progress.
Nurse Clarke: You're already taking a lot of steps in the right direction to take care of yourself.
Gregory: It's a bit of two steps forward, one step back sorta deal. I'm trying though.
Coach: Nice. You affirmed Gregory's efforts to change, reinforcing his positive behavior.
Nurse Clarke: What do you know about the risks of having another heart attack, and what we can do to prevent it?
Coach: Good job! Your open-ended question allowed Gregory to share his knowledge without fear of judgment.
Gregory: I guess... Depends on what I do going forward, right?... but if I had to, I'd say...
Gregory: I... could have another. Don't know any numbers or what have you, but...Just know I'm never really gonna, "get better," you know? Mine's not a question of if... but when.
Nurse Clarke: It seems like you could have another health challenge, so it's important to prevent it.
Gregory: I'd... like that to be true. I'm just not sure it is.
Nurse Clarke: So you're questioning how much changing your behavior is impacting your health, and at the same time,it would be better if you had the confidence to build up your own health.
Gregory: Exactly.
Coach: Good! You reflected Gregory's perception about his risk.
Nurse Clarke: Let me go over what we've talked about so far, to make sure we're on the same page.
Gregory: Okay.
Nurse Clarke: So far I'm hearing you've succeeded at staying smoke freeand you've been taking your meds to protect your heart and keep the stents open.And all that is pretty important to you because...
Nurse Clarke: ... you want to do what you can to increase your chances of having a full life.
Gregory: Yeah... even thought my brother wasn't so lucky, maybe it'll make a difference for me.
Coach: Excellent! Your reflection showed Gregory you not only pay attention to what he has to say, you are interested in partnering with him to address his overall well-being.
Gregory: I don't know though. All this is so... discouraging.
Nurse Clarke: You've put a lot of work in to stay smoke-free and take your medication, which should make a big difference.
Gregory: I appreciate that. I'm trying. I guess it could be making a difference.
Nurse Clarke: Given all you have accomplished so far, it seems like it is.
Gregory: Maybe so.
Coach: Nice! Your affirmation mentioned specifically what Gregory has done for his health which helped him feel appreciated and capable.
Nurse Clarke: Sounds like you're open to thinking about what next steps might look like.
Coach: Nice! Your reflection picked up on Gregory's change talk.
Gregory: Yeah, I'm ready. Let's do it.
Nurse Clarke: So... In terms of ways to continue improving your cardiovascular health... What are your thoughts?
Coach: Nice! By keeping the question open-ended, you allow Gregory to identify options that he is more likely to choose and follow through with.
Gregory: Well, at first I thought the rehab program would be okay.I liked the sense of community. Kinda like being in the Air Force again.
Nurse Clarke: Our cardiac rehab programs are often described like,a supportive environment where veterans help other veterans make healthy choices.
Gregory: Yeah, I mean, it sounds great on paper. But somehow it didn't just click with me.
Coach: Your normalizing statement led Gregory to share more about his experience, opening a path for you to explore what worked and what didn't work for him.
Nurse Clarke: What happened when you tried our cardiac rehab program?
Gregory: I was starting to feel better. A lot of those veterans were dealing with way worse stuff than I was.But... It just didn't feel right.
Nurse Clarke: What didn't feel right?
Gregory: It was like, they were treating us all the same! And I didn't like how they were, talking down to us,and expecting us to fall into line. We were sheep to them.
Coach: Good job! By asking Gregory an open-ended question, you gave him the space to express himself and answer honestly.
Nurse Clarke: It sounds like the lecturing was a problem for you, while at the same time,you felt a connection to the other veterans, and got some initial benefits.
Gregory: Yeah, being with the other veterans made it easier to say something when I felt like I was being treated like a kid.
Nurse Clarke: So you and the other veterans felt like you could rely on each other.
Gregory: I did like that part a lot... one time, ah, I forget her name,but she was telling us about how important it was to eat vegetables,and asks us what we were eating, right? And this one guy looks her dead in the eye and says,"I put lettuce and tomato on every burger I eat."When she said that wasn't good enough, he stood up and pointed to the poster on the wall."Y'see that? Lettuce and tomato. I rest my case" We enjoyed that. Feels like moments like that make the tough parts a little easier.
Gregory: Yeah... I mean- it might be worth giving it another shot.I'll have to think on it. Keep in mind what's important to me.
Coach: Great! Your double-sided reflection showed Gregory you were actively listening to his concerns and led to him expanding on what he liked about the program.
Nurse Clarke: Like, being around longer, the way you wish other people in your life could have been.
Gregory: I mean, that's true. I've been thinking about them a lot recently.Maybe the changes came a little late for my brother...but if I can make a difference in my own health, and be around longer for my family, I'd want that.
Coach: Great! You accurately identified and reflected what Gregory said is important to him, which evoked change talk about follow-through and self-care.
Gregory: And... I guess it's really my choice, whether or not I want to give the rehab program another try...
Gregory: I think the program might be worth another try.
Nurse Clarke: That sounds like a good choice.
Gregory: But I could see myself doing more for my health, outside the rehab program too.
Nurse Clarke: Okay... Sure.
Nurse Clarke: I'd like to work together and set a specific,measurable goal that you can try to achieve over the next couple weeks.How's that sound?
Coach: Asking how Gregory feels about setting a specific goal is a good way to foster collaboration and effective action planning.
Gregory: That sounds good. What kind of goal?
Nurse Clarke: Well, other than being specific and measurable, it should be realistic.We don't want to aim for something you don't feel you'll be able to hit.
Gregory: Got it... Uhh... I might need a moment to think about it.
Nurse Clarke: That's fine.
Nurse Clarke: You mentioned earlier working on physical activity, limiting fried foods, and cutting back on alcohol.All those are good ideas to consider.
Coach: Asking an open-ended question like "what would you like to focus on" encourages Gregory to develop a plan that works best for him, which he is more likely to want to follow.
Gregory: I think I'd be... open to getting more exercise, if I wanted to do something.
Nurse Clarke: What do you think you could do to get more exercise?
Gregory: I mean... I could try golfing more, when I have a little more energy.
Nurse Clarke: Okay... So you want to get more exercise, and eventually golf more.With that in mind, what would be a small step that could get you started?
Gregory: Uh... I could go with my wife when she goes for a walk every morning before breakfast, and every night after dinner.
Nurse Clarke: How realistic is the goal to join your wife on her daily walks?
Gregory: Well... sometimes I go over to my neighbors to watch a game, or play cards.So, I guess it is not that realistic to go every day.
Nurse Clarke: Well, we want to try and set a goal you feel is doable.
Gregory: I could shoot for going with her 4 times a week, starting this weekend. That feels doable, at least as a start.
Coach: Asking an open-ended question like "how realistic is it..." gives Gregory the space to consider all the possibilities of whether or not he has set a goal he can realistically achieve.
Nurse Clarke: I'd like to make sure you're gradually increasing your physical activity.How long does your wife usually spend walking? And how fast does she go?
Gregory: Usually a half hour, right as the sun is going down. It's pretty around then, and a decent temperature.And she's a pretty intense woman... when we've walked in the past, I've worked up a bit of a sweat. Nothing too crazy.
Nurse Clarke: So your wife doesn't push you too hard, just hard enough to get good exercise.
Gregory: Yeah.
Nurse Clarke: How will you keep track of how often you're walking?
Gregory: I guess... I could make a note of it in my calendar. Shouldn't be a big deal.
Nurse Clarke: Sounds good.
Coach: Asking open-ended questions allows you and Gregory to develop a more specific, measurable, and realistic plan.
Nurse Clarke: This goal seems reasonable. And every step counts.
Gregory: All right. I feel good about that...
Coach: Great! By affirming Gregory's efforts, you let him know he is on a path to effective change.
Gregory: Maybe once I get started I can find some other ways to fit exercise in.You know, with my buddies. Some of them actually like to walk the course...I've been using a cart, but I know I don't get much exercise with the cart.
Nurse Clarke: That sounds like a great next step, whenever you feel ready for it.
Gregory: Yeah. Thanks.
Nurse Clarke: So let's focus in on how you're feeling about your goal.On a scale from zero to ten how confident are you to stick with this plan,with zero being not at all confident and ten being extremely confident?
Gregory: I would say... a seven. Out of ten.
Coach: Nice job! Using the confidence scale can help you identify and then communicate about Gregory's ability to achieve his plan, and also identify any potential barriers to change.
Nurse Clarke: Why did you choose a seven instead of a lower number like a five?
Gregory: I'm pretty good at following through when I decide to do something, and this feels pretty doable.Also, I know my wife'll be happy about this, and will probably stop getting on my case as much.Which makes everything easier! . So you're pretty confident based on the fact that you feel this plan is doable,you have your wife's support, and you're generally pretty determined.
Gregory: Exactly.
Coach: Great! Asking what made Gregory choose a seven instead of a lower number encourages him to share change talk and to feel more empowered about making a behavior change.
Nurse Clarke: So, what would make it an even higher number, like an eight or a nine?
Gregory: Hmm... well, I know I get in the middle of something and don't really like to stop.So, my confidence might be higher if I could figure out some way of addressing that.
Nurse Clarke: What could you do about that?
Gregory: Well, I could always put on the DVR... catch up with the game or show after we get back.That would probably put me closer to an eight, maybe a nine.
Nurse Clarke: Sounds like a good plan to keep in mind.
Gregory: Agreed!
Coach: Nice job! Using the higher end of the confidence scale to identify barriers is a good way to help him prepare for challenges that he might face.
Gregory: Who knows... this actually might be kind of fun.
Gregory: You know... I was pretty sure I was going to come in today,and you were going to get upset with me for slipping up, you know?I'm glad we could just talk and figure something out.
Nurse Clarke: From what I've seen, if you're the one who sets the goals, you'll have a much easier time following through.
Gregory: That's a good way to look at things.
Nurse Clarke: I think we're done for today. Could you take me through the plan we talked about?
Gregory: Okay, sure. I'm going to...
Gregory: Go for a walk with my wife at least 4 times a week, starting this weekend...
Gregory: We'll go for around a half hour each time, enough to push myself a little...
Gregory: I'll throw on the DVR if I feel like I might miss something I'm watching...
Gregory: As a stretch goal, when I'm feeling up to it, I might try to walk instead of taking the golf cart around...
Gregory: And I'll probably give the cardiac rehab program another try.
Nurse Clarke: That all sounds good. I'll set up a time to call you and check in over the next couple weeks, if that's okay with you.
Gregory: That sounds good to me... Thank you.
Nurse Clarke: All right, thanks so much for talking, Gregory.When would be a good time around two weeks from now for me to call you and check in on how your goal is going?
Gregory: Maybe two weeks from tomorrow, after four.
Nurse Clarke: That sounds good. Thanks again for coming in today.
Gregory: Sure thing.
Coach: Gregory left his appointment with a plan to go on some walks with his wife, and despite his mixed experiences the last time he tried the cardiac rehab program, he wanted to give it another shot.
Coach: Gregory was feeling pretty good after talking with Nurse Clarke. At his next checkup, he was still smoke-free, did not have any new cardiovascular symptoms, and he was enjoying the walks with his wife. He even mentioned that he had met a new friend through the cardiac rehab program.
Nurse Clarke: Good to see you again, Mr. Mitchell.
Gregory: Call me Gregory... And, yeah, good to see you, too, under... better circumstances.
Nurse Clarke: You're looking good, since the procedure!
Gregory: Thanks. Been a whirlwind of a month, that's for sure.Come a long way since the last time I was here, when I was... not in great shape.
Nurse Clarke: So, today we're going to focus on how you've been since your procedure.
Gregory: Sure.
Nurse Clarke: That sound good to you?
Gregory: Yup.
Coach: By setting the agenda, you missed an opportunity to ask Gregory what he wanted to work on. The more collaborative the conversation, the more Gregory will feel included, and engaged.
Nurse Clarke: On your chart I saw your blood pressure is looking a little high, and you dropped out of our cardiac rehab program.
Gregory: I'm trying my best. That's good enough for me.
Nurse Clarke: The results say you could be doing more.
Gregory: I'm taking my meds, and I haven't had a cigarette for weeks.Past that, only results I care about is how I feel. And I feel pretty good, to be honest.
Coach: Relying too heavily on the chart, rather than having a conversation, distanced you from Gregory. Instead, explore more of Gregory's efforts, experience, or perspective before sharing so much information.
Nurse Clarke: After a procedure like yours, we like to be mindful of the usual suspects -exercising, eating healthy, you know. I hope you've kept up with all that...
Gregory: I've been trying to smoke less, take those meds you all prescribed.
Nurse Clarke: That's a good start, but there's always ways to do better. Right?
Coach: Though you intended to encourage Gregory, it came off as vague advice. And by not acknowledging the efforts he's already made, it seems like you think he hasn't made progress.
Nurse Clarke: I... I don't know. I'm glad I'm getting better. It's just- it's a lot of changes.
Gregory: What do you mean?
Nurse Clarke: All this pressure to get more exercise, the idea of never smoking again,drinkin' less, giving up the food I've enjoyed my whole life...
Gregory: I know it's what I gotta do, but... it's tough is all.
Nurse Clarke: It's important to look after your heart.
Gregory: Yeah. I know.
Nurse Clarke: If you don't look after your cardiovascular health, you could---could have another heart attack. I get it.
Nurse Clarke: Okay then.
Coach: Sharing information without asking permission or exploring what Gregory knows can provoke discord. Consider acknowledging Gregory's challenges while also exploring his beliefs and motivation.
Nurse Clarke: It sounds like you're giving it your best, and that's what matters, right?
Gregory: That's how I see things.
Nurse Clarke: I hear how important it is for you to feel better.
Gregory: Just taking things a day at a time.
Coach: Vague encouragement can come across as disingenuous and dismissive if challenges are not acknowledged. Consider exploring Gregory's ideas for making changes for his health.
Nurse Clarke: You should keep in mind your biggest reasons for staying healthy.
Gregory: Why?
Nurse Clarke: Just something to think about.
Gregory: Sure.
Coach: Being too direct with Gregory came across as you simply telling him what to do. Instead reflect or ask about his motivations for change.
Nurse Clarke: Given how challenging it can be to make changes to a routine,a lot of patients find it helpful to keep in mind a specific reason for staying healthy.
Gregory: Carrot on the end of a stick, huh.Sort of, maybe a little more empowering than that.
Gregory: Just teasin' ya. Well...
Coach: You normalized Gregory's challenges with making healthy changes. However, it would've been even more effective to focus more on Gregory's experience and understanding and ask him what would motivate him to stay healthy.
Gregory: I love my family. I still remember holding my daughter Michelle for the first time. And then her son James.The other day I was tossing a baseball with James and... after the first couple tosses back and forth I-I started missing the catches.It even started to be a challenge to bend down, and pick up the ball.I... didn't like that.
Nurse Clarke: Not keeping up with your grandson is making you think about getting older, and feeling more frail.
Gregory: Not really... I don't feel frail.I just got surgery and I'm still keeping up with my grandkids! As best I can at least.
Nurse Clarke: Of course, that makes sense.
Gregory: I'm just saying... I'm not exactly who I used to be.
Coach: While you tried to reflect Gregory's desire to keep up with his grandkids, your reflection went a bit too far. Because it was a reflection, it gave Gregory a chance to correct your assumption and provided you with an opportunity to explore his motivations further.
Nurse Clarke: Your grandkids are pretty active, and you don't want them to think of you as weak.
Gregory: Weak? I know I won't be able to keep up with my grandkids forever.Right now, I should be healthy enough, and eventually I know I won't be. That's just how getting older works.
Nurse Clarke: But you said you wanted energy-- I guess, but that's probably just a part of getting older.
Coach: While you tried to reflect Gregory's desire to keep up with his grandkids, your reflection went a bit too far. Because it was a reflection, it gave Gregory a chance to correct your assumption and provided you with an opportunity to explore his motivations further.
Nurse Clarke: Let's make a plan to help you keep making healthy choices.
Gregory: Uh... sure. A plan, huh?
Coach: By pushing ahead to make a plan, you're missing an opportunity to reflect what Gregory has shared and affirm the efforts he has already made. Instead, by reflecting and affirming you can help Gregory feel more ready to make plans.
Gregory: Well, at first I thought the rehab program would be okay.I liked the sense of community. Kinda like being in the Air Force again.
Nurse Clarke: You should give our cardiac rehab program one more try. It's a great resource to help people like you.
Gregory: Erm... sure... why not...
Nurse Clarke: Great! Glad to hear it.
Gregory: Maybe it'll be easier if I keep in mind what's important to me.
Coach: Giving your unsolicited opinion didn't leave space for Gregory to consider options and partner on a plan. Instead, consider exploring what didn't work for him and what might help him follow through.
Nurse Clarke: Like, keeping up with younger people when you do hard work.
Gregory: ... sure. I mean, I do want to keep feeling better...
Coach: This reflection is off the mark. Remembering and reflecting Gregory's stated reasons for change will help build rapport, partnership, and motivation to follow though.
Gregory: At the same time, I doubt it'll make a difference...
Gregory: I'm just not sure the program is for me.
Nurse Clarke: That's okay. You can keep considering the rehab program, and we can think about trying something else.
Nurse Clarke: We should set a goal for the next couple weeks.
Gregory: Okay, boss. Just give me a minute to think about it.
Nurse Clarke: Take your time.
Coach: Telling Gregory what he should do puts him on the defensive, and makes it more difficult for him to set a goal that he feels motivated to achieve.
Nurse Clarke: I think you should eat healthier meals. That will make a big difference.
Coach: Advising Gregory to do something he previously expressed reluctance to do is likely to elicit arguments against changing. Instead, consider asking Gregory what he wants do to stay healthier.
Gregory: Uh... let me think. Kinda caught me off guard.
Gregory: No. I like what I eat. I'd rather get a little more exercise.
Nurse Clarke: Eating healthy would have a huge impact-I don't want to. Okay? I could see myself getting out, going for walks with my wife.
Nurse Clarke: Okay... we should make that goal a little more clear.
Gregory: ... fine.
Gregory: Uh... I could go with my wife when she goes for a walk every morning before breakfast, and every night after dinner.
Nurse Clarke: I think we're done for today. Could you take me through the plan we talked about?
Gregory: Okay, sure. I'm going to...
Gregory: Go for a walk with my wife every morning before breakfast, and every night after dinner...
Gregory: And... maybe I'll think about giving the cardiac rehab program another try.
Nurse Clarke: That all sounds good. I'll set up a time to call you and check in over the next couple weeks, if that's okay with you.
Gregory: Yup.
Nurse Clarke: All right, thanks so much for talking, Gregory.When would be a good time around two weeks from now for me to call you and check in on how your goal is going?
Gregory: Maybe two weeks from tomorrow, after four.
Nurse Clarke: That sounds good. Thanks again for coming in today.
Gregory: Sure thing.
Coach: Gregory left his appointment with a plan to go on some more walks with his wife, and to think about going back to the cardiac rehab program.
Coach: Gregory didn't feel encouraged by this conversation, and he remained ambivalent about cardiac rehab and making any changes to his behavior. At his next appointment, he was not interested in following through with rehab and hadn't gotten much exercise, though he managed to stay smoke-free.
Nurse Clarke: Good to see you again, Mr. Mitchell.
Gregory: Call me Gregory... And, yeah, good to see you, too, under... better circumstances.
Nurse Clarke: You're looking good, since the procedure!
Gregory: Heh! Well, considering before the procedure, I was lying half dead on a table... I'll take it.
Nurse Clarke: Sounds like it was a little scary for you, last time you were here.
Gregory: I know you folks are professionals and all, but when you all rushed me in...I wasn't sure what was happening to me. I remember the doctor saying she had to put stents in...to keep me from having a lot more damage to my heart. Didn't expect to hear that when I woke up that morning!
Coach: Great! This empathic reflection built rapport and spurred Gregory to elaborate.
Nurse Clarke: How have things been at home since your procedure?
Gregory: Oh, you know. I'm doing fine, but my wife is always bugging me about this or that.
Nurse Clarke: And what's that like?
Gregory: I mean, she gets on my case about the same thing, over and over again.
Coach: Good job! By asking an open-ended question about Gregory's home life, it shows that you care about his "whole health," not just his heart condition.
Nurse Clarke: I hear you, it feels like your wife is looking over your shoulderwhen you're the one in charge of managing your recovery, and that's frustrating.
Gregory: Exactly! I got it covered, and she's worried all the time. She's a good woman.But after all this time, she really knows how to piss me off!
Nurse Clarke: So you two are pretty close?
Gregory: I know exactly what she's thinking, and she knows exactly what I'm thinking... it's that kind of thing.
Coach: Nice! You responded with a complex reflection to show you're interested in Gregory's perspective and how he feels, which encouraged him to open up about his wife with you.
Nurse Clarke: What branch are you with, Gregory?
Gregory: Air Force, former airman, first class.
Nurse Clarke: My uncle served in the Air Force. Good people there.
Gregory: You know it. The best.
Coach: Great! You built rapport by asking Gregory about his service.
Nurse Clarke: Well let's get started. What do you know about why Dr. Cantwell wanted us to talk today?
Gregory: Honestly?... I'm not sure why Dr. Cantwell sent me your way... I've been feeling pretty good since the procedure,back to living the way I want, for the most part. Pretty fast recovery for someone at my age, huh!
Nurse Clarke: Glad to hear you're feeling better.What do you think you need in order to keep your recovery going in the right direction?
Gregory: I dunno... I guess if you've got some recommendations, I'll hear you out, but...I think it's just a matter of time before I'm feeling like myself again.
Nurse Clarke: It's great you're feeling better, and you're open to talking about keeping your heart strong.
Coach: Great job! Gregory's attention shifted to planning and collaboration as he considered your open-ended question.
Coach: Good! Gregory's attention shifted to planning and collaboration as he considered your open-ended question. Though Gregory would've felt more comfortable if you had first acknowledged his fears and struggles from his past procedure.
Gregory: I don't know how much I have to say about all that. I'm pretty happy with my life right now.And I don't want to hear you tell me about how the things I like are bad for me. I'm gonna do what I want to do.
Nurse Clarke: What have you been doing to strengthen your cardiovascular health the last three weeks?
Gregory: Well, when I left the hospital, the plan was to get exercise when I could,whether by walking with my wife or playing golf with my buddies.They also talked to me about giving up smoking, trying to eat less fried food, and drinking less.
Nurse Clarke: And how's all that going?
Gregory: Okay, I suppose. I haven't had a cigarette for... 23 days now,and I've been taking all my meds, the blood pressure ones and the new ones to protect my heart.So I've been starting to... live the way I like to live. Feeling pretty good about it.
Nurse Clarke: Staying smoke free is a very important way to improve your cardiovascular health.
Gregory: Exactly. And as time goes on, I'm just going to keep getting stronger.
Coach: Great job! You asked an open-ended question that encouraged Gregory to share the positive changes he made for his cardiovascular health.
Nurse Clarke: It's great that you've stayed smoke free.It's the most important way to keep your heart healthy and prevent another heart attack.And it's great that you've been consistently taking your meds.
Gregory: Yeah, they told me the medication would help keep the stents open, so... been takin' 'em.And I know how important it is for me to stay smoke-free. But also, I'm just healing up over time.
Coach: By affirming Gregory's specific efforts to live a healthier life and follow through with medications, you let him know that you're aware of the progress he's making.
Nurse Clarke: Your effort to stay smoke free and take your medication... these are all impressive accomplishments.Now it's about building on the good work you've already done.
Gregory: I guess... huh.
Nurse Clarke: What?
Coach: Your affirmation helped Gregory feel that his efforts matter, though be careful about making assumptions about his follow-through with other behaviors. Consider asking about these.
Gregory: I mean... MAYBE the stuff I've been doing so far has made a difference.But now that I'm feeling better, that might change what I want to do next.
Nurse Clarke: How are you feeling about the progress you've made so far?
Coach: Great! This open-ended question tapped into Gregory's experience in a non-judgmental way, which spurred him to respond genuinely and share his feelings.
Gregory: I mean... it's hard! There's a lot of, "you can't do this, and you can't do that"...I'm just trying to enjoy my life, you know? And how much of a difference is all this really going to make?
Nurse Clarke: Tell me a little more about that.
Gregory: All this pressure to get more exercise, the idea of never smoking again,drinking less, giving up the food I've enjoyed my whole life...
Gregory: ... you know what I mean? It's like this huge thing, and- it's tough.
Nurse Clarke: I hear you don't like what you're giving up. What do you think you're gaining?
Gregory: Well, my wife and my kids get off my back. That's definitely a good thing.
Nurse Clarke: So making those choices would reduce how much your family gets on your case, and make them happier.
Gregory: Yeah... it pisses me off when anyone tells me what I need to do... I like them a lot better when they're more mellow.
Coach: Good job! Your initial reflection was accurate and addressed Gregory's feelings, while your open-ended question about benefits shifted the focus to reasons for change that are important to him.
Nurse Clarke: You're in charge of your own health. It's your choice.
Gregory: I trust myself, you know? I think I generally make good choices. I mean... I've managed to get me this far!
Coach: Nice job! Emphasizing Gregory's autonomy showed him that you respect and honor his decision-making.
Nurse Clarke: You're facing your health condition with a lot of determination.
Gregory: Oh come on.
Nurse Clarke: I'm serious. A lot of people feel overwhelmed by changes in their life, and they give up. It seems like you've been committed to improving your situation.
Gregory: I guess... it's frustrating, all I have to give up.
Coach: Nice! By affirming Gregory's efforts, you showed you were listening to him and valuing the changes he's already made.
Nurse Clarke: You've made a number of great choices already, you stopped smoking, you're taking your meds, and you showed up today.
Gregory: I'm just trying my best. But thanks.
Coach: Good! Your affirmation of Gregory's specific efforts reminded him he is on the right track to achieve his goals.
Nurse Clarke: On a scale from zero to ten,how important is it for you to make some of the recommended changes to keep your heart strong,with zero being not at all important and ten being the most important?
Gregory: I guess I'd have to say... a five? Could go either way, honestly.
Coach: Good job! Using the importance scale is an effective and judgment-free way to explore how important change is to Gregory and to evoke "change talk" about what is behind that level of importance.
Nurse Clarke: Why did you say a five, rather than a lower number, like a three?
Gregory: I'm not even sure it's a five, honestly... it might be more like a four.
Nurse Clarke: Well, why a four rather than a three, or a two?
Gregory: I guess... there are things that make me want to keep going, push myself.Being able to play catch or lift a box at work without feeling winded.
Coach: Good job! By exploring why Gregory's rating of importance wasn't lower, you elicited change talk and learned more about his motivations.
Nurse Clarke: How would staying healthy make a difference in your life?
Gregory: It's probably too late for me to play major league, huh. Probably.
Gregory: Well, I've already done a lot in my life...
Coach: Great open-ended question to further explore core elements of motivation !
Gregory: When I was in the service,I could haul a good hundred pounds of gear on my back and still climb into a chopper no problem.These days at work, I start feeling winded after a couple big packages...
Nurse Clarke: It seems like you want to feel more like yourself when you were younger.
Gregory: I mean, I'm no spring chicken. But at work... the younger guys talk down to me, sometimes right to my face.They have no idea what I've carried on my shoulders, my whole life.
Nurse Clarke: That sounds frustrating.
Gregory: Kids are gonna be kids. I'm not about to get all "back in my day" on you, but...sure would be nice to have the stamina to do my job.
Coach: Great! You accurately reflected Gregory's experience which led to more disclosure and more change talk!
Nurse Clarke: So you want to be healthy enough to keep working as long as you can, and feel more like yourself.
Gregory: It feels good to put in a hard day's work and know that I... accomplished something.
Nurse Clarke: And it seems like looking after your own health might help with feeling more capable at work.
Gregory: Maybe. I mean, I can do my job well enough.But it sure would be nice to stay shoulder to shoulder with the younger guys and not feel so tired after.
Coach: Good! Your accurate reflection showed Gregory you were listening to his concerns.
Nurse Clarke: Any step forward is a step forward.
Gregory: Seems like a pretty low standard, no?
Nurse Clarke: I have plenty of patients who aren't able to quit and stay quit for as long as three weeks.Kicking a habit like tobacco use isn't easy, it's an impressive accomplishment.
Gregory: Maybe it is.
Coach: Nice work! Affirming Gregory's specific efforts to live a healthier life helps him understand that you know he's trying to make progress.
Nurse Clarke: What do you know about the risks of having another heart attack, and what we can do to prevent it?
Coach: Good job! Your open-ended question allowed Gregory to share his knowledge without fear of judgment.
Gregory: I guess... Depends on what I do going forward, right?... but if I had to, I'd say...
Gregory: I... could have another. Don't know any numbers or what have you, but...Just know I'm never really gonna, "get better," you know? Mine's not a question of if... but when.
Nurse Clarke: It seems like you could have another health challenge, so it's important to prevent it.
Gregory: I'd... like that to be true. I'm just not sure it is.
Nurse Clarke: So you're questioning how much changing your behavior is impacting your health, and at the same time,it would be better if you had the confidence to build up your own health.
Gregory: Exactly.
Coach: Good! You reflected Gregory's perception about his risk.
Nurse Clarke: Let me go over what we've talked about so far, to make sure we're on the same page.
Gregory: Okay.
Nurse Clarke: So far I'm hearing you've succeeded at staying smoke freeand you've been taking your meds to protect your heart and keep the stents open.And all that is pretty important to you because...
Nurse Clarke: ... you want to have the stamina to keep up at work, more like you used to.
Gregory: Yeah. I know I'll have to stop working eventually, but... for now, I want to keep feeling useful, working hard.
Coach: Excellent! Your reflection shows Gregory you not only pay attention to what he has to say, but you care for his overall well-being.
Gregory: I don't know though. All this is so... discouraging.
Nurse Clarke: You've put a lot of work in to stay smoke-free and take your medication, which should make a big difference.
Gregory: I appreciate that. I'm trying. I guess it could be making a difference.
Nurse Clarke: Given all you have accomplished so far, it seems like it is.
Gregory: Maybe so.
Coach: Nice! Your affirmation mentioned specifically what Gregory has done for his health which helped him feel appreciated and capable.
Nurse Clarke: Sounds like you're open to thinking about what next steps might look like.
Coach: Nice! Your reflection picked up on Gregory's change talk.
Gregory: Yeah, I'm ready. Let's do it.
Nurse Clarke: So... In terms of ways to continue improving your cardiovascular health... What are your thoughts?
Coach: Nice! By keeping the question open-ended, you allow Gregory to identify options that he is more likely to choose and follow through with.
Gregory: Oh no, you're not going to bring up that cardiac rehab program, are you? It's really not for me.
Coach: You may want to work with Gregory to navigate his discord in order to see if he'd reconsider the cardiac rehab program. Move on when you feel you are out of constructive choices.
Nurse Clarke: Sounds like, despite some mixed feelings about going to the rehab program, you gave it a chance.
Gregory: I didn't last very long, just a couple of days... too many lectures... "prescriptions for exercise".
Nurse Clarke: So, you didn't like the way it was coming across... and at the same time, tried it out.
Gregory: Yeah, that's true.
Coach: Great! Gregory appreciated your acknowledgment of both his concerns and his effort, which may open the door for further consideration of rehab as an option.
Nurse Clarke: What's your understanding of the purpose of cardiac rehab programs?
Gregory: To... provide a whole lot of boring lectures and tell us how we're supposed to live our lives.
Nurse Clarke: So that was your sense from your time there.
Gregory: Yup.
Coach: Great! This question was neutral and open-ended, allowing Gregory to respond honestly and earnestly.
Nurse Clarke: It sounds like the rehab folks that you worked with were too preachy.I'm sorry to hear that. I know that doesn't work for many Veterans.
Gregory: If I wanted to go to church, I would have gone to church, if you know what I mean.
Nurse Clarke: Definitely. Can I go on?
Gregory: Sure.
Nurse Clarke: My understanding is that they should offer you options for the education piece,including handouts and links to resources online as an alternative to group classes.They also offer individual sessions with a nursewho can help you with your personal plan for physical activity and healthy eating. What are your thoughts about that?
Gregory: Hm. Well, that sounds different from what I experienced. I don't know though... I don't want to get another bad draw.
Coach: Great job! By asking permission before you gave information, you made Gregory feel like you were speaking with him, and not at him.
Nurse Clarke: You're weighing the pros and cons, and trying to decide what to do here.
Gregory: It just don't know what good it's going to do, you know? I knew plenty of people who did stuff like this, and they still ended up dropping dead.
Coach: Nice job! You reflected Gregory's ambivalence, which made him feel heard and more open to hearing you out and collaborating on solutions.
Nurse Clarke: While I know you gave it a try,can I share with you some info about how cardiac rehab programs can reinforce your healthy choices?
Gregory: Can't hurt.
Nurse Clarke: People are much less likely to have another heart attack if they complete a cardiac rehab program,especially when they make lifestyle changes, like stopping smoking. You've already accomplished that!
Nurse Clarke: Okay if I go on?
Gregory: Sure.
Nurse Clarke: Making healthy choices isn't easy, and it won't work for everyone... at the same time,my patients who participate tell me they feel more confident and more in charge of their life after participating.And some really like the support they get from other Veterans.It's kind of like preparing for a mission together. What do you think of that?
Coach: Because you asked permission, Gregory was more receptive and is more seriously considering rejoining the cardiac rehab program. Notice also how Nurse Clark provided information in small chunks and emphasized Veteran engagement and empowerment.
Gregory: I can see some value to that... I don't know about preparing for a mission, but... I get being prepared.I know there's a lot of... changes, my family is dealing with right now.Around me, and my heart. Gotta be ready to take on whatever comes next.
Nurse Clarke: Exactly.
Nurse Clarke: What do you think you want to do now?
Gregory: Well, I think we've talked enough about the rehab program. I'm not sure what I wanna do...but I'll figure it out. Keep in mind what's important to me.
Nurse Clarke: Like, keeping up with younger people when you do hard work.
Gregory: Being able to go into work every day without feeling so... weak?That would make me a lot happier. Feel more like I used to...
Coach: Great! You accurately identified and reflected what Gregory said is important to him, which evoked change talk about follow-through and self-care.
Gregory: And... I guess it's really my choice, whether or not I want to give the rehab program another try...
Gregory: I think the program might be worth another try.
Nurse Clarke: That sounds like a good choice.
Gregory: But I could see myself doing more for my health, outside the rehab program too.
Nurse Clarke: Okay... Sure.
Nurse Clarke: I'd like to work together and set a specific,measurable goal that you can try to achieve over the next couple weeks.How's that sound?
Coach: Asking how Gregory feels about setting a specific goal is a good way to foster collaboration and effective action planning.
Gregory: That sounds good. What kind of goal?
Nurse Clarke: Well, other than being specific and measurable, it should be realistic.We don't want to aim for something you don't feel you'll be able to hit.
Gregory: Got it... Uhh... I might need a moment to think about it.
Nurse Clarke: That's fine.
Nurse Clarke: You mentioned earlier working on physical activity, limiting fried foods, and cutting back on alcohol.All those are good ideas to consider.
Coach: Asking an open-ended question like "what would you like to focus on" encourages Gregory to develop a plan that works best for him, which he is more likely to want to follow.
Gregory: I think I'd be... open to getting more exercise, if I wanted to do something.
Nurse Clarke: What do you think you could do to get more exercise?
Gregory: I mean... I could try golfing more, when I have a little more energy.
Nurse Clarke: Okay... So you want to get more exercise, and eventually golf more.With that in mind, what would be a small step that could get you started?
Gregory: Uh... I could go with my wife when she goes for a walk every morning before breakfast, and every night after dinner.
Nurse Clarke: How realistic is the goal to join your wife on her daily walks?
Gregory: Well... sometimes I go over to my neighbors to watch a game, or play cards.So, I guess it is not that realistic to go every day.
Nurse Clarke: Well, we want to try and set a goal you feel is doable.
Gregory: I could shoot for going with her 4 times a week, starting this weekend. That feels doable, at least as a start.
Coach: Asking an open-ended question like "how realistic is it..." gives Gregory the space to consider all the possibilities of whether or not he has set a goal he can realistically achieve.
Nurse Clarke: I'd like to make sure you're gradually increasing your physical activity.How long does your wife usually spend walking? And how fast does she go?
Gregory: Usually a half hour, right as the sun is going down. It's pretty around then, and a decent temperature.And she's a pretty intense woman... when we've walked in the past, I've worked up a bit of a sweat. Nothing too crazy.
Nurse Clarke: So your wife doesn't push you too hard, just hard enough to get good exercise.
Gregory: Yeah.
Nurse Clarke: How will you keep track of how often you're walking?
Gregory: I guess... I could make a note of it in my calendar. Shouldn't be a big deal.
Nurse Clarke: Sounds good.
Coach: Asking open-ended questions allows you and Gregory to develop a more specific, measurable, and realistic plan.
Nurse Clarke: This goal seems reasonable. And every step counts.
Gregory: All right. I feel good about that...
Coach: Great! By affirming Gregory's efforts, you let him know he is on a path to effective change.
Gregory: Maybe once I get started I can find some other ways to fit exercise in.You know, with my buddies. Some of them actually like to walk the course...I've been using a cart, but I know I don't get much exercise with the cart.
Nurse Clarke: That sounds like a great next step, whenever you feel ready for it.
Gregory: Yeah. Thanks.
Nurse Clarke: So let's focus in on how you're feeling about your goal.On a scale from zero to ten how confident are you to stick with this plan,with zero being not at all confident and ten being extremely confident?
Gregory: I would say... a seven. Out of ten.
Coach: Nice job! Using the confidence scale can help you identify and then communicate about Gregory's ability to achieve his plan, and also identify any potential barriers to change.
Nurse Clarke: Why did you choose a seven instead of a lower number like a five?
Gregory: I'm pretty good at following through when I decide to do something, and this feels pretty doable.Also, I know my wife'll be happy about this, and will probably stop getting on my case as much.Which makes everything easier! . So you're pretty confident based on the fact that you feel this plan is doable,you have your wife's support, and you're generally pretty determined.
Gregory: Exactly.
Coach: Great! Asking what made Gregory choose a seven instead of a lower number encourages him to share change talk and to feel more empowered about making a behavior change.
Nurse Clarke: So, what would make it an even higher number, like an eight or a nine?
Gregory: Hmm... well, I know I get in the middle of something and don't really like to stop.So, my confidence might be higher if I could figure out some way of addressing that.
Nurse Clarke: What could you do about that?
Gregory: Well, I could always put on the DVR... catch up with the game or show after we get back.That would probably put me closer to an eight, maybe a nine.
Nurse Clarke: Sounds like a good plan to keep in mind.
Gregory: Agreed!
Coach: Nice job! Using the higher end of the confidence scale to identify barriers is a good way to help him prepare for challenges that he might face.
Gregory: Who knows... this actually might be kind of fun.
Gregory: You know... I was pretty sure I was going to come in today,and you were going to get upset with me for slipping up, you know?I'm glad we could just talk and figure something out.
Nurse Clarke: From what I've seen, if you're the one who sets the goals, you'll have a much easier time following through.
Gregory: That's a good way to look at things.
Nurse Clarke: I think we're done for today. Could you take me through the plan we talked about?
Gregory: Okay, sure. I'm going to...
Gregory: Go for a walk with my wife at least 4 times a week, starting this weekend...
Gregory: We'll go for around a half hour each time, enough to push myself a little...
Gregory: I'll throw on the DVR if I feel like I might miss something I'm watching...
Gregory: As a stretch goal, when I'm feeling up to it, I might try to walk instead of taking the golf cart around...
Gregory: And I'll probably give the cardiac rehab program another try.
Nurse Clarke: That all sounds good. I'll set up a time to call you and check in over the next couple weeks, if that's okay with you.
Gregory: That sounds good to me... Thank you.
Nurse Clarke: All right, thanks so much for talking, Gregory.When would be a good time around two weeks from now for me to call you and check in on how your goal is going?
Gregory: Maybe two weeks from tomorrow, after four.
Nurse Clarke: That sounds good. Thanks again for coming in today.
Gregory: Sure thing.
Coach: Gregory left his appointment with a plan to go on some walks with his wife, and despite his mixed experiences the last time he tried the cardiac rehab program, he wanted to give it another shot.
Coach: Gregory was feeling pretty good after talking with Nurse Clarke. At his next checkup, he was still smoke-free, did not have any new cardiovascular symptoms, and he was enjoying the walks with his wife. He even mentioned that he had met a new friend through the cardiac rehab program.
Nurse Clarke: Good to see you again, Mr. Mitchell.
Gregory: Call me Gregory... And, yeah, good to see you, too, under... better circumstances.
Nurse Clarke: You're looking good, since the procedure!
Gregory: Heh! Well, considering before the procedure, I was lying half dead on a table... I'll take it.
Nurse Clarke: So, today we're going to focus on how you've been since your procedure.
Gregory: Sure.
Nurse Clarke: That sound good to you?
Gregory: Yup.
Coach: By setting the agenda, you missed an opportunity to ask Gregory what he wanted to work on. The more collaborative the conversation, the more Gregory will feel included, and engaged.
Nurse Clarke: On your chart I saw your blood pressure is looking a little high, and you dropped out of our cardiac rehab program.
Gregory: I'm trying my best. That's good enough for me.
Nurse Clarke: The results say you could be doing more.
Gregory: I'm taking my meds, and I haven't had a cigarette for weeks.Past that, only results I care about is how I feel. And I feel pretty good, to be honest.
Coach: Relying too heavily on the chart, rather than having a conversation, distanced you from Gregory. Instead, explore more of Gregory's efforts, experience, or perspective before sharing so much information.
Nurse Clarke: You're feeling better because of your efforts to stay healthy.
Gregory: Maybe... a number of times in my life, I've been in a tricky situation and pulled through all right.Makes me think that what I do doesn't have much to do with how things go.
Coach: Your choice to affirm is a good one, though be careful of statements that are overly simplistic and consider further exploration of Gregory's beliefs and experience.
Nurse Clarke: I'm proud of what you've done so far, Gregory.
Gregory: Proud of me? Sure.
Nurse Clarke: No really, I'm impressed with what you've done.
Gregory: I guess... huh.
Nurse Clarke: What?
Coach: Though affirmations can build rapport, this one was vague and may have felt disingenuous to Gregory. Instead, identify and affirm specific positive steps he has taken.
Gregory: I- I don't know.
Nurse Clarke: Don't know what?
Gregory: I've tried to look after myself, but... I don't know what that means for me. About what comes next.
Nurse Clarke: It seems like you've made some progress with healthy choices, but at the same time, I know you can do a lot better.
Coach: Though you may intend to encourage, pushing Gregory to "do better" triggered some push back and discord. Consider exploring his ideas for making further changes.
Gregory: I mean... it's hard! There's a lot of, "you can't do this, and you can't do that"...I'm just trying to enjoy my life, you know? And how much of a difference is all this really going to make?
Nurse Clarke: Tell me a little more about that.
Gregory: All this pressure to get more exercise, the idea of never smoking again,drinking less, giving up the food I've enjoyed my whole life...
Gregory: ... you know what I mean? It's like this huge thing, and- it's tough.
Nurse Clarke: I get this can feel overwhelming. But I'm concerned, especially with your medical history.
Gregory: I know my, "medical history". And you don't need you to be "concerned" about me, okay? My wife has that one covered.
Coach: Your effort to acknowledge Gregory's feelings is admirable, though "but, I'm concerned" felt dismissive. Instead, consider exploring his understanding and motivation.
Nurse Clarke: I'm a little worried about your risk for substance use now, because of when you used heroin in Vietnam.
Gregory: Because of my- !? Man, that was so long ago.I get that, but-You get it? Boy, how old were you in 1969? Huh? Yeah, that's what I thought.
Coach: You were pushy in focusing on Gregory's past heroin use, which is a touchy subject for him. Rather than telling him a worry you have, it would be more effective to explore his motivations or show appreciation for the changes he has already made.
Nurse Clarke: You should be a little more concerned about the strength of your heart. Here we go.
Nurse Clarke: I just want to make sure you know what's at stake here.
Gregory: I get it, okay? Man. You folks always-
Nurse Clarke: Always what?
Gregory: Never mind. Forget it.
Coach: Trying to persuade Gregory by telling him he should be more concerned, came across as lecturing him. It would be more effective to accept Gregory's current level of readiness for change and appreciate the changes he has already made.
Nurse Clarke: You should keep in mind your biggest reasons for staying healthy.
Gregory: Why?
Nurse Clarke: Just something to think about.
Gregory: Sure.
Coach: Being too direct with Gregory came across as you simply telling him what to do. Instead reflect or ask about his motivations for change.
Nurse Clarke: Given how challenging it can be to make changes to a routine,a lot of patients find it helpful to keep in mind a specific reason for staying healthy.
Gregory: Carrot on the end of a stick, huh.Sort of, maybe a little more empowering than that.
Gregory: Just teasin' ya. Well...
Coach: You normalized Gregory's challenges with making healthy changes. However, it would've been even more effective to focus more on Gregory's experience and understanding and ask him what would motivate him to stay healthy.
Gregory: These days- what I'm really thinking about is my dad, and my brother.One time, growing up, a car started rolling down a hill where we were parked, and they ran over, caught it,pushed it back up until it was safe, and the driver came back. Hm.Didn't stop their hearts giving out when they got older. I-I don't want to end up like that.
Nurse Clarke: You're thinking about your dad and brother, and how strong they were.
Gregory: I guess, but also that it... didn't help them, in the end. So... maybe it doesn't matter what I do. I don't know. If I could be around longer... I'd want that.
Coach: Your reflection prompted Gregory to share more of his beliefs about his risks for heart disease and provides an opening for exploring what he might do about it.
Nurse Clarke: You think your dad and brother might have lived longer if they made healthier choices.
Gregory: I don't think so. I mean, I don't know for sure, but they- they tried their best.Maybe people put too much pressure on them, you know? And they just decided to enjoy being alive.
Nurse Clarke: That could be. But you're here now,so we need to figure out what choices you're going to make for your health, with them in mind.
Gregory: Yeah... we share blood, for better or worse.
Coach: While you tried to tap into Gregory's motivation by making a link between healthy choices and his family members' early death, Gregory experienced this as pushing him to change and he pushed back. Instead, consider reflecting Gregory's actual change talk.
Nurse Clarke: Let's make a plan to help you keep making healthy choices.
Gregory: Uh... sure. A plan, huh?
Coach: By pushing ahead to make a plan, you're missing an opportunity to reflect what Gregory has shared and affirm the efforts he has already made. Instead, by reflecting and affirming you can help Gregory feel more ready to make plans.
Gregory: Oh no, you're not going to bring up that cardiac rehab program, are you? It's really not for me.
Coach: You may want to work with Gregory to navigate his discord in order to see if he'd reconsider the cardiac rehab program. Move on when you feel you are out of constructive choices.
Nurse Clarke: C'mon bud, you're tough. I know you can do it.
Gregory: I know I can do it, I just don't want to do it.
Nurse Clarke: That sounds like fear talking, to me, my friend. Where's the fire, Gregory? You got this.
Gregory: Pfft. Sure.
Coach: Using a term of endearment like "bud" and pushing him to try rehab again led Gregory to push back. Instead, consider exploring his motivation using reflections, affirmations, and open-ended questions.
Nurse Clarke: What do you think you want to do now?
Gregory: Well, I think we've talked enough about the rehab program. I'm not sure what I wanna do...but I'll figure it out. Keep in mind what's important to me.
Nurse Clarke: Like, your wife, and how much she means to you.
Gregory: ... sure. I mean, I do want to keep feeling better...
Coach: This reflection is off the mark. Remembering and reflecting Gregory's stated reasons for change will help build rapport, partnership, and motivation to follow though.
Gregory: At the same time, I doubt it'll make a difference...
Gregory: I'm just not sure the program is for me.
Nurse Clarke: That's okay. You can keep considering the rehab program, and we can think about trying something else.
Nurse Clarke: I think we're done for today. Could you take me through the plan we talked about?
Gregory: Okay, sure. I'm going to...
Gregory: Keep on doin' what I've been doin'.
Gregory: I'm going to stay smoke-free, and continue my medications...
Gregory: And... maybe I'll think about giving the cardiac rehab program another try.
Nurse Clarke: That all sounds good. I'll set up a time to call you and check in over the next couple weeks, if that's okay with you.
Gregory: Yup.
Nurse Clarke: All right, thanks so much for talking, Gregory.When would be a good time around two weeks from now for me to call you and check in on how your goal is going?
Gregory: Maybe two weeks from tomorrow, after four.
Nurse Clarke: That sounds good. Thanks again for coming in today.
Gregory: Sure thing.
Coach: Gregory left his appointment with a plan to consider the cardiac rehab program again.
Coach: Gregory didn't feel encouraged by this conversation, and he remained ambivalent about cardiac rehab and making any changes to his behavior. At his next appointment, he was not interested in following through with rehab and hadn't gotten much exercise, though he managed to stay smoke-free.
Janet is a 56-year-old Veteran. She has been a heavy smoker for many years and was diagnosed with coronary heart disease six months ago and experiences episodes of chest pain (stable angina pectoris). She takes medication to manage her angina and high cholesterol, and is not currently a candidate for a procedure to address her heart disease.
As Nurse Clarke, an RN care manager on a PACT team, you are meeting with Janet after she’s seen the physician during today’s appointment.
CONVERSATION GOALS
Explore Janet’s perspective on her health and encourage her to identify what is important for her to work on.
Use Reflective Listening to deepen your understanding of Janet’s concerns and empathize with her feelings and past struggles.
Use a Shared Decision Making approach to share information about options for smoking cessation and collaborate with Janet on ways to improve her health.
Assist Janet, if she’s ready, in setting a SMART goal and an initial plan.
Nurse Clarke: Hello Ms. Lopez. Our last chat was six months ago. It's good to see you again!
Janet: Good to see you too, Nurse Clarke.
Nurse Clarke: Ok so... you've just seen the doctor....your blood pressure is good,and your recent blood work looks good. How are you doing?
Janet: Eh. I'm doin' all right. Can't *... Can't complain.
Nurse Clarke: Great to hear.
Nurse Clarke: How have you been lately?
Janet: I have another exhibit coming up - it's taking up most of my time lately...
Nurse Clarke: Art, right? Painting?
Janet: That's it.
Nurse Clarke: I can imagine that putting something together like that takes a lot of energy and focus.
Janet: Yes... But I... fit in a little exercise when I can like we talked about last time...Something's better than nothing, right?
Nurse Clarke: So how's the art exhibit going?
Janet: Ok, I guess. Just this week I've been getting my website together, figuring out spacing things with the gallery,and I wasn't happy with how the postcards turned out so I've been back and forthing with the designer...I'm sorry, I'm rambling. Boring details. We can talk about something else.
Nurse Clarke: Not boring at all... but if you like, we can switch topics.
Coach: Nice! When you asked about the exhibit, Janet felt like you had a genuine interest in her and her well-being.
Janet: I'm just happy I've managed to exercise as much as I have.
Nurse Clarke: Nice to hear you're keeping up the exercise. How's it been going?
Janet: Not half-bad! I walk along the beach and chat on the phone with my friend Margaret.
Nurse Clarke: Walking is a wonderful way to keep in shape without taxing the body too much.And you've incorporated a fun way to enjoy yourself in the process.
Janet: Right. I get my walk in and I get to catch up with my friends.And I'm happy to keep doing it, especially since walking doesn't take up too much time...
Coach: Great job! Janet appreciated that you reaffirmed her efforts to stay healthy, especially since her schedule is so busy
Janet: I got other priorities, too.
Janet: Like that my health situation has been getting bigger than... just me... lately.My grandkids, for instance. They don't totally understand what's going on, like when I have chest pains, but they know something's up.
Nurse Clarke: Your grandkids are concerned about you.
Janet: They really do care. I mean, they're adorable... Felix and Cody are their names. Twins.On Sundays they come over and we stroll around the garden hand-in-handand they tell me about their week, and ask me how I'm doing.
Nurse Clarke: That is adorable.
Janet: Except when they decide to be smart-asses and try to switch names. Newsflash: grandma always knows who's who...Anyhoo, they keep me active.
Coach: Good! This nonjudgmental reflection gave Janet the space to talk about her relationship with her grandkids, and their concern about her well-being.
Janet: But look - weren't we here to ... to talk about my health?
Nurse Clarke: What can you tell me about your health these days?
Janet: Well, I still get chest pains, like we chatted about last time.
Coach: Nice! Your open-ended question let Janet go into detail about one of her main concerns: her chest pain.
Janet: Doesn't feel like I'm about to have a... heart attack or anything. Doesn't make 'em any less annoying though.
Nurse Clarke: When have you been noticing the chest pains? Any times different from our previous session?
Janet: Eh, they've stayed pretty consistent since last time. Still only notice 'em when I'm stressed.Or sometimes if my grandkids try to get me to run around.Or... I guess I notice it sometimes when it's cold out, or I'm walking up the hill near my house.Just the... price of doing what you enjoy, I suppose
Nurse Clarke: So, what's your understanding of the connection between smoking and chest pain?
Janet: I know that smoking affects your heart and can lead to heart attacks.It just that sometimes, even after I have chest pain, I still want a smoke.
Nurse Clarke: So for you, the connection works both ways.
Coach: Good! You asked Janet to share her understanding and she answered in an honest and open way.
Nurse Clarke: And how do you feel about smoking?
Janet: I mean, I've been smoking my whole life. I'm at a pack a day - and I enjoy it.I know stopping would be better for my health, but I don't have time to quit right now.
Nurse Clarke: You've been a smoker for a long time and you are not sure you have time to quit right now,THOUGH you know that quitting could improve your chest pains,reduce your risk of a heart attack or stroke and make a real difference in your health.
Janet: I mean, yes I know if I cut down I'd probably reduce the coughing and the chest pains.But I just don't know how realistic me quitting at this age would be. Even with any other... benefits...
Coach: Great job! You used a double-sided reflection that first acknowledged Janet's ambivalence and then reflected and affirmed Janet's knowledge of the connection between smoking and chest pain.
Nurse Clarke: Like easing your grandkids concerns about your health...
Janet: Yeah, exactly.
Coach: Great! You remembered and reflected an important reason for staying healthy that Janet shared with you, which sparked change talk!
Janet: My grandkids. On one hand, they complain about me:"The house smells grandma. The car smells too. YOU smell, grandma"...I love 'em, but they should talk to their grandmother with some respect.Still, the other day, they caught me clutching my chest and they ran over. I was fine, but ...
Janet: It's just... quitting is already hard to even think about.So to actually do it again and deal with all the other crap that happens to your body?Please. I do not need that in my life
Nurse Clarke: Tell me about the challenges you faced quitting in the past.
Janet: I suppose the biggest one was I would get... cranky.Like Frankenstein cranky. And I'm supposed to be the nice grandma! You seem nice enough to me! ...Besides getting cranky, were there any other issues you were concerned about?
Janet: Well, not to be superficial or anything, but I really don't want to get, well... fat.It ain't easy for a lady to lose weight at this age, you know.
Nurse Clarke: Tell me more about how you're concerned you'll gain weight.
Janet: Well, I've never quit long enough to experience it myself.But my pal Susie managed for about a month. Blew up like a blimp and kept it.
Nurse Clarke: You're worried when you quit smoking you'll put on a significant amount of weight,and have difficulty losing it afterwards.
Janet: Yeah, poor Susie.... she was so stressed from the weight gain, she started smoking again.
Coach: Great! By asking Janet to tell you more about how she's concerned she'll gain weight, you showed you're taking her concerns seriously.
Nurse Clarke: I have some information about weight gain after quitting smoking that I can share, if you like?
Janet: Sure.
Nurse Clarke: There is a chance you'll gain some weight, that's true.Though the average person who quits smoking only gains around 5-10 pounds. How do you feel about that?
Janet: Oh... that's not so bad. I thought I'd need to buy a whole new wardrobe.
Coach: Good! You asked permission before sharing information with Janet. She felt like her opinion was being taken into account and she was more receptive to hearing what you said.
Nurse Clarke: Even if you gain weight, the exercise you've been doing could help you lose those pounds.And exercise is something you've been able to keep up and even enjoy!
Janet: Right. Hmmm.
Coach: Great! You affirmed the specific efforts Janet has already made for her health.
Janet: Something to think about, I guess.
Janet: What about me becoming a grinch? And all that other junk that'll happen to my body?
Nurse Clarke: What other withdrawal symptoms have you experienced in the past?
Janet: Well, besides getting cranky, my hands shake, which makes it hard to paint.And after a long day of not smoking and not painting, I end up not sleeping.Which makes it even harder to concentrate on anything the next day.
Coach: Great! You asked an open-ended question to learn more about Janet's specific experience with withdrawal symptoms and how they impacted her life. This allows you to discuss options that may address her specific concerns.
Nurse Clarke: So in the past when you've tried to quit, you've found you get cranky,your hands shake and you have trouble sleeping. Which all makes it difficult to focus.
Janet: Yeah.
Nurse Clarke: Those symptoms are common nicotine withdrawal symptoms experienced by many people when they quit smoking.
Janet: Great. I don't take a lot of pleasure in being in the majority.
Nurse Clarke: The good news is, these symptoms will become less severe over time.The first few days are the hardest, and for most people withdrawal symptoms resolve within a couple of weeks.
Janet: Hmm, I don't know about 'good' news. But I guess you could say it's 'not terrible' news...
Coach: Good choice! The accurate reflection of Janet's experience and subsequent explanation is a first step in partnering with her to address this important barrier.
Nurse Clarke: How have you dealt with your withdrawal symptoms in the past?
Janet: Mainly just what I mentioned earlier, the patch, the gum...
Nurse Clarke: And what's your understanding of other options to help quit?
Janet: Well, I know there's fancy medicines these days, including inhaler thingees...
Janet: I guess there's a few solutions out there.... But... I just...
Janet: UGH... I JUST can't concentrate on any of this right now.I feel like-- I don't know. I hear you... but I need more time to think.
Nurse Clarke: You've got a lot going on so it's hard to focus,even though you might be interested in learning more about quitting later on.
Janet: You got that right.
Nurse Clarke: Tell me more about what in particular is making it so tough right now.
Janet: This exhibit... I'm excited for it... but... it's getting to me. You know how it goes.The second you have everything handled, something else pops up. The gallery asked me to reschedule after I already sent the invitations...it's really just not the right time to kick bad habits.
Nurse Clarke: All the stress of the art exhibit and its unknowns have made it tough to talk about smoking cessation options.Though if the timing were different, it might be something you'd be open to.
Janet: Exactly, at some point down the road, just not now.
Nurse Clarke: That's totally OK. Always ready to talk.
Janet: Thanks... I appreciate it. You've given me something to think about.I might even chat to my family a little more before then, see what they have to say.
Nurse Clarke: I think that's a great plan.
Coach: Great job! You used a double-sided reflection to acknowledge Janet's current ambivalence about discussing smoking cessation while also highlighting the her change talk. Janet appreciates that you're not trying to push her to do something she's not ready to do.
Nurse Clarke: I'd love to summarize what we talked about so far before you go.If I understood you correctly you're concerned about your chest pains and heart disease,and their connection to smoking.
Nurse Clarke: Your family seems concerned about it too, and they matter a whole lot to you.
Nurse Clarke: So much so that you're willing to talk about quitting smoking, just not right now because of your upcoming art show.
Janet: That sounds right to me.
Nurse Clarke: Great. Is there anything else you'd like to discuss today?
Janet: No... I think I'm good.
Nurse Clarke: When would be a good time for you to return to talk some more about options for quitting smoking?
Janet: Well, the exhibit is in six weeks. The earliest I could come back here would be... two months from now.
Nurse Clarke: That would be great! Why don't you make an appointment on the way out?
Janet: OK. I'll be back... probably... eventually. Wish me luck in the meantime!
Nurse Clarke: Of course. Good luck with your exhibit!
Coach: Great! You chose to summarize what the two of you discussed today even though Janet wasn't ready to talk about smoking cessation yet. This allows her to confirm that you understood her correctly and gives her a chance to add anything important that wasn't mentioned.
Coach: Two months later, Janet returns for another visit...
Nurse Clarke: Hi Janet . Glad you came back to talk again.
Janet: Our last conversation stuck with me I guess, and since my schedule cleared up,I've had a lot more headspace to... well, let's get started.
Coach: Janet's return for this visit suggests she has been thinking seriously about her smoking. Now is a good time to find out more about her ideas, feelings and preferences about quitting.
Nurse Clarke: What are you hoping to accomplish today?
Janet: I'm trying to see what quitting would look like for me... I guess I just want to see what's out there,see if there's anything I'm missing that could help me get past the usual roadblocks.
Nurse Clarke: I'm glad to hear you're interested in getting some help, addressing some concerns.I am happy to explore options with you.
Janet: Perfect.
Coach: Great! By asking Janet what she'd like to accomplish, you empowered her to consider and share her goals as well as some concerns she would like help with.
Nurse Clarke: On a scale from 0 to 10, how important is it for you to quit?With zero being not important at all, and 10 being very important.
Coach: Great choice. Using the importance scale with Janet will help you gauge her current motivation, providing opportunity for further exploration.
Janet: If I didn't think it was important, I wouldn't have driven all the way over here. Probably... a 7.
Nurse Clarke: What made you say that number and not something lower...
Coach: Nice job! Asking what made her choose that number instead of a lower one is a great way to elicit her motivations.
Nurse Clarke: ...like a 6 for example?
Janet: Well, it's because... uhh... it's that important because...I think about how different things are today than when I was younger. Like how...
Janet: ...my son grew up with me smoking in the house. But my grandkids...they see me cough and... I just want to be the best grandma I can be.
Nurse Clarke: It's important to take care of yourself, so they don't worry as much.
Janet: Exactly. If I found a way to quit smoking, it would do a lot for my relationship with them.
Coach: Your reflection made Janet feel heard. You also emphasized an important reason for change -- improving her relationship with her family.
Nurse Clarke: How would you feel about going over some smoking cessation options like you mentioned at the end of our last visit?...should you choose to go that route.
Coach: Excellent! Janet appreciated that you first asked for permission before sharing information.
Coach: Excellent! Janet appreciated that you first asked for permission before sharing information. However, it may be more effective to use the Importance Scale first. Remember, undoing is an option.
Janet: I'd like to know what these magic solutions are you think I haven't tried, but so we're clear,I don't know if I'm ready to commit to anything today, or at all for that matter.
Nurse Clarke: Sure. I'll take you through some quitting techniques we support here at the VA:counselling, medications, behavioral strategies. And while they each help in different ways,we find patients have the most success when they combine the strategies.
Nurse Clarke: What strategies do you want to talk about first? They can be the ones I named, or something different...
Janet: I didn't come in here today with a plan in mind. I only know what's helped in the past and what definitely hasn't.
Nurse Clarke: Which things are the ones you think might help?
Janet: Hm... I've quit a dozen times before, but I never follow through. So I guess anything that might help me stick with it.
Nurse Clarke: You're not positive what's going to help, but you'd like to explore strategies that help with follow-through.
Janet: Exactly.
Coach: Asking Janet about the strategies that she prefers to discuss supports her autonomy and may increase her receptiveness to the strategies that you might share.
Nurse Clarke: If you're looking for continued support, I could tell you a little about counseling.
Coach: Good choice! You offered an opportunity to learn more about counseling.
Nurse Clarke: To put it in your words, someone to help you "stick with it" if you start to slip.We have resources like that here at the VA.
Coach: Good choice! You offered an opportunity to learn more about counseling. Nurse Clarke's use of Janet's own words further enhanced this approach.
Janet: I remember people telling me about group therapy programs when I stopped drinking.I see the benefit, but- but I never tried it myself. It all felt too... public. Not this grandma...
Nurse Clarke: I've known patients who had a lot of success with more private solutionslike quitlines you can call and even text message.
Janet: That's not so public... but I barely use my cell phone as it is.
Nurse Clarke: There are services that do private in-person sessions as well.
Janet: Okay... that would address my issue with the group thing... something to think about....I know a lot about counselling already, so let's just move on.
Nurse Clarke: Fine with me.
Coach: Good choice! You shared information that was tailored to Janet's preferences and needs, which increased her receptiveness and evoked some change talk.
Nurse Clarke: What do you know about behavioral strategies for quitting?
Coach: Good choice. Continue to explore Janet's understanding of behavioral strategies.
Janet: Isn't the behavior "stop smoking"? I don't know what you mean.
Nurse Clarke: Like specific actions you can take to set yourself up for success.
Janet: Everyone is always telling me to quit right away. I've never really taken much time to "set up" quitting."No time like the present." That's what my son tells me when it comes up but...it's never the right time, like before, with my art show. It's too stressful.
Nurse Clarke: Trying to quit right away can be stressful, but there are actually lots of benefits to preparing instead of diving in.Can I share some of those with you?
Janet: Go ahead.
Nurse Clarke: There are things you can do to reduce the stress of quitting, like...hiding or throwing away your cigarettes or your ashtrays or other reminders of smoking...And you can think about how you'll respond when you do encounter triggers before it happens.
Janet: Huh. I've never tried that. Usually someone gets me all worked up,I quit right then and there, and I'm smoking again by dinner.
Coach: Good! You asked permission before sharing information. The more Janet participates in the planning, the more receptive and motivated she is likely to be.
Nurse Clarke: Now that we've talked a little about it, how do you feel about the idea of preparing to quit ahead of time?
Janet: Well it's definitely a different strategy than I've heard before- you know, the usual stuff for nicotine cravings.
Nurse Clarke: In what way?
Janet: It's not just handling symptoms. It kind of helps with the planning part too.It's interesting; that's all. I'll think about it.
Coach: Good choice to ask about interest in taking steps to prepare for quitting!
Nurse Clarke: How would you feel talking about something you could do during the actual quitting process?Not a quit day, but something more concrete.
Janet: I think I'd like that a lot. That's more what I was looking for when I came in today.
Coach: Great idea to ask permission to support Janet's autonomy and honor her preferences!
Nurse Clarke: You mentioned that you struggled with withdrawal symptoms whenever you try to quit.For that we recommend specific medications, things you mentioned trying like gums,lozenges, and patches. How did that work for you?
Janet: The short answer? It didn't. I've been smoking since the Navy, too long for quick-fixes.
Nurse Clarke: What do you mean?
Janet: I'm not some schoolkid smoking clove cigarettes behind the dumpster. I smoke over a pack a day.The gum was good for a quick craving, but it didn't get me close to the finish line.
Coach: Good! You chose to ask an open-ended question and Janet shared her experience with medications for withdrawal symptoms and her understanding of their potential effectiveness for her.
Nurse Clarke: Tell me more about that.
Janet: That's all there is to tell.
Nurse Clarke: You said the gum was good for a quick craving. In what way?
Janet: I just noticed that, compared to the other times I've tried quitting, I didn't... it wasn't as extreme. You know?Like, the spikes when I needed a cigarette. It's not like it kept me smoke-free for good.
Coach: Good choice! Exploring Janet's experience of the week she noted some benefit may help you and her build on previous success.
Nurse Clarke: Would it be okay if I shared how medications like gum work when paired with some other strategies?
Janet: Can you explain what you mean?
Nurse Clarke: Nicotine replacement products mostly work to reduce withdrawal symptoms like shakiness or irritability.The idea is to reduce those symptoms so it's easier to follow through with other quitting strategies.
Janet: That would have been great - but that's not what happened.
Nurse Clarke: Maybe you weren't getting enough nicotine. Our pharmacists could help you sort out a more effective dosage.
Janet: I'll think about it.
Coach: Good job! You asked Janet's permission to continue to share information and tailored your comments to address her needs. As a result, she expressed some interest in this option. You are making progress.
Nurse Clarke: To summarize what we talked about, you might be interested in some of these quitting strategies.
Coach: Great choice! A summary provides an opportunity to reflect interest and motivation and to transition towards collaborating on a specific plan.
Nurse Clarke: In-person counseling sounds appealing.
Nurse Clarke: Medication to help with cravings, for example.
Nurse Clarke: ...and planning ways to manage your smoking triggers.
Nurse Clarke: It's especially great that you're willing to consider all three together.We've found patients have had the most success when the combine strategies.
Janet: There's more to it than I realized...
Nurse Clarke: Than you realized? What do you mean?
Janet: To tell the truth, I wasn't actually planning on coming back after our last visit, but... my grandkids...a few days after my show, I found a pack of cigarettes in their toybox at my house...so I asked them about it, they said they were hiding it from me.I think they look at me like I'm helpless.
Nurse Clarke: But you want to find a way to change that... be their role model.
Janet: Yeah... I do.
Janet: In case I do decide I want to talk to the VA smoking person, I was wondering if you could tell me what that might look like.
Nurse Clarke: We can absolutely support you with that decision.
Nurse Clarke: I think it's great you're thinking about diving in right away.The planning process usually starts with setting something we call SMART goals. Can I tell you about those?
Janet: Please do.
Nurse Clarke: SMART goals are smaller benchmarks that we can set towards the bigger goal of quitting smoking.They should be specific, measurable, action-oriented, realistic, and time-based- smart!Basically, you want to pick something you can realistically achieve.
Janet: Like quitting permanently?
Coach: Great work! Janet appreciated that you asked for permission before sharing information about SMART goals.
Nurse Clarke: Quitting permanently is a great long term objective and challenge.For a SMART goal, we might want to consider setting something smaller and more achievable.
Janet: Okay that sounds better. How about...
Coach: Great! You first affirmed Janet's motivation to quit and then prompted her to think about smaller action steps. Now she has a SMART goal!
Janet: ...scheduling the actual meeting with the VA smoking person.
Nurse Clarke: That sounds perfect! When do you think you could do that?
Janet: I can probably make that happen this Friday. I don't have any deadlines coming up or anything.
Nurse Clarke: Wonderful.
Nurse Clarke: How confident are you that you'll reach your goal on a scale of zero to ten;zero being not at all confident and ten being extremely confident?
Coach: Good job! Using this scale gave Janet the space to honestly gauge her confidence in achieving her goal.
Janet: Let's say an eight.
Nurse Clarke: What made you say that and not a lower number? Like a 4.
Janet: I think just... what you were saying... like considering those strategies. I feel like I know what I'm getting myself into. You know?
Coach: Nice! You helped Janet reflect on the strengths that led her to choose that number.
Janet: I've heard a lot of this stuff that we talked about before, but I think I have a better handle on it now.
Nurse Clarke: What would make you say an even higher number like a 9?
Janet: Hmmm... I don't know. I guess I still have a few concerns, like... since my last visit, actually,I've noticed more than ever how smoking is a part of my daily life...
Coach: Asking what would make confidence higher helps to identify barriers that may interfere with reaching goals. Once barriers are revealed, you can explore options for addressing them.
Janet: ...like with my friends. I just... I think it'll be hard to quit when smoking is, sort of, what we do together.Like the other day I met up with some friends for coffee.By the end of the afternoon, I had smoked like half a pack.What am I supposed to do when they smoke? Fiddle with my hands?
Nurse Clarke: What alternatives can you think of?
Coach: Good job putting Janet at the center of brainstorming solutions. She'll feel more ownership of a plan she helped come up with!
Janet: Like doing something instead of Sunday coffee? Are you crazy? No thank you.
Nurse Clarke: It doesn't have to be that. Whatever you think would work for you.
Janet: Maybe... we could go somewhere they don't let you smoke on the patio.We're always trying new places anyway. Then again, my friends wouldn't be able to smoke there...
Nurse Clarke: You want a simple smoking replacement that doesn't change your routine.
Janet: Hm... you know a friend just gave me one of those puzzle books- crosswords, sudoku, stuff like that.
Coach: Great job responding to barriers with a reflection that prompted Janet to identify a potential solution.
Janet: It fits into my purse... and I could pull it out if my friends start smoking...
Nurse Clarke: Great.
Nurse Clarke: You're working hard to take steps to better your health,and everyone here at the VA wants to support you however we can.
Janet: I've worked hard for fifty-six years, raised two kids all on my own... I'm not afraid of a little hard work.
Nurse Clarke: It's hard work, but it's important work, which is why it's so significant you came back to talk today.We'll meet again soon to keep up with your cardiovascular health.
Janet: I appreciate it. Thanks again... for everything!
Coach: After this visit, Janet spoke with a smoking cessation counselor. They discussed her preference for nicotine gum, and about going to one-on-one sessions. She set a quit day on her grandkids' birthday and at her next visit she reported that she hadn't smoked for 30 days.
Nurse Clarke: Hello Ms. Lopez. Our last chat was six months ago. It's good to see you again!
Janet: Good to see you too, Nurse Clarke.
Nurse Clarke: Ok so... you've just seen the doctor....your blood pressure is good,and your recent blood work looks good. How are you doing?
Janet: Eh. I'm doin' all right. Can't... Can't complain.
Nurse Clarke: Great to hear.
Nurse Clarke: Seems like your cough hasn't improved since the last session.
Janet: Oh you noticed?
Nurse Clarke: Well, coughing is common in chronic smokers...
Janet: Coughing I can live with. These chest pains on the other hand...
Coach: Good observation, though it would be better to ask open-ended questions about Janet's agenda for the visit and to explore her concerns.
Nurse Clarke: Let's talk about how you're doing with the chest pains we discussed last time...
Janet: I still have them. And they're not getting any better.
Coach: By choosing the agenda, you miss an opportunity to explore what's important to Janet. Instead, you can try asking open-ended questions about Janet's agenda for the visit and her concerns.
Janet: Doesn't feel like I'm about to have a... heart attack or anything. Doesn't make 'em any less annoying though.
Nurse Clarke: When have you been noticing the chest pains? Any times different from our previous session?
Janet: Eh, they've stayed pretty consistent since last time. Still only notice 'em when I'm stressed.Or sometimes if my grandkids try to get me to run around.Or... I guess I notice it sometimes when it's cold out, or I'm walking up the hill near my house.Just the... price of doing what you enjoy, I suppose
Nurse Clarke: Smoking causes heart disease, and heart disease causes chest pains.
Janet: Well, I'm not an idiot. I know that.And for the record sometimes I want to have a smoke after the chest pains, just to get a little relief.
Nurse Clarke: So for you, the connection works both ways.
Coach: When you shared information without asking permission or asking what Janet knew, she felt belittled and pushed back. Next time, try exploring what she knows about the connection between smoking and chest pains.
Nurse Clarke: And how do you feel about smoking?
Janet: I mean, I've been smoking my whole life. I'm at a pack a day - and I enjoy it.I know stopping would be better for my health, but I don't have time to quit right now.
Nurse Clarke: Well, when WOULD be a good time to quit?
Janet: I don't know... but... just... not NOW.
Coach: Though you asked an open question, it was a challenging one. Consider using reflections to respond to her concerns and her 'change talk' and further explore her motivation.
Nurse Clarke: Since you recognize the damage smoking causes, maybe you should consider quitting smoking.
Janet: Yeah, but I also recognize 'should' and 'could' are not the same thing:just because it's better for me, doesn't make it any easier to contemplate, let alone do.
Nurse Clarke: Quitting is difficult to even think about right now, while at the same time,you know that you'd be in better health if you did quit.
Janet: I mean, yes in that I know if I had never smoked I probably wouldn't have these health issues to begin with.And... well, I suppose there would be some other... benefits...
Coach: Instead of suggesting quitting, consider using reflections or questions to explore Janet's beliefs and motivation . Note the benefit of Nurse Clarke's subsequent reflections.
Nurse Clarke: Other benefits?
Janet: Yeah. But look... I got a lot going on right now.
Janet: I have another exhibit coming up - it's taking up most of my time lately...
Nurse Clarke: Art, right? Painting?
Janet: That's it.
Nurse Clarke: I can imagine that putting something together like that takes a lot of energy and focus.
Janet: Yes... But I... fit in a little exercise when I can like we talked about last time...Something's better than nothing, right?
Nurse Clarke: A 'little' exercise is nice, but last time we discussed more than 'a little'.
Janet: I walk along the beach and chat on the phone with my friend Margaret. Seems like it does the job.
Nurse Clarke: So how often are you walking and for how long?
Janet: Eh, around half an hour. Like two or three times a week.
Nurse Clarke: Half an hour is okay, but really you should be aiming for five or more days a week.
Janet: I'm fifty-six years old. Walking three times a week is as much as I can manage.
Coach: You may be well-intentioned in telling Janet that she should be exercising more, but she felt as if you were pushing her to do something unrealistic. If you had reaffirmed the efforts Janet already made, she may feel more encouraged to continue making healthy choices.
Janet: And with my work and the exhibit and everything.
Nurse Clarke: Maybe this isn't the best time to be doing something so stressful.
Janet: What do you mean 'best time'? Look, my show's really one of the most important things I have right now.I've already got my website together, figured out my painting placements with the gallery.Look, the exhibit's very important to me. That's all you need to know. Let's talk about something else.
Nurse Clarke: Sure, we can change topics.
Coach: Rather than make a suggestion, consider using an open-ended question to ask Janet about her concerns, needs, and priorities, especially early in the visit.
Janet: There's just other things I'd rather talk about while I'm here.
Janet: Like just making sure what I have doesn't get worse. Like my friend Bridgette.I mean, she didn't have heart disease, but she did develop emphysema soon after she started smoking again and... it didn't turn out well.
Nurse Clarke: If you quit smoking that would reduce your risk of heart attack or strokeand keep your bronchitis from getting worse.
Janet: Yes. I do know that. But you never really know, do you?I've got friends who've smoked since they were sixteen, never any issues.And then there's Bridgette who started smoking again in retirementafter quitting in her 20's, and then she's the one to get sick...
Nurse Clarke: I'm sorry to hear that Janet. And I can only imagine having that happen to someone you knewmakes you consider minimizing your risk of further heart disease.
Janet: Here's hoping.
Coach: Sharing medical facts and trying to persuade led Janet to argue against your advice. Consider asking permission to share information or exploring her understanding of risks.
Nurse Clarke: So you recognize there are some other benefits to quitting smoking....
Janet: Yeah, I guess there would be some other... benefits...too
Nurse Clarke: Like saving money to use for something else...
Janet: Hmm, yeah. I guess that's kinda important... Not totally what was on my mind... but,anyway, I know there are advantages to quitting smoking. It's just... not that easy to actually do...
Coach: This was not what Janet mentioned as important to her previously. Recalling important conversation details like a patient's motivations for change can be a great way to connect with patients and remind them of their goals.
Janet: It's just... quitting is already hard to even think about.So to actually do it again and deal with all the other crap that happens to your body?Please. I do not need that in my life
Nurse Clarke: Tell me about the challenges you faced quitting in the past.
Janet: I suppose the biggest one was I would get... cranky.Like Frankenstein cranky. And I'm supposed to be the nice grandma! You seem nice enough to me! ...Besides getting cranky, were there any other issues you were concerned about?
Janet: Well, not to be superficial or anything, but I really don't want to get, well... fat.It ain't easy for a lady to lose weight at this age, you know.
Nurse Clarke: Let's put aside withdrawal symptoms for a moment and focus on the smoking-induced issues.
Janet: It's not that easy for me... sometimes the withdrawal symptoms ruin my whole day.
Nurse Clarke: Can you tell me more about how they've affected you in the past?
Janet: Well, besides getting cranky, my hands shake, which makes it hard to paint.And after a long day of not smoking and not painting, I end up not sleeping.Which makes it even harder to concentrate on anything the next day.
Coach: Janet felt like you weren't taking her concerns seriously. Consider responding to Janet's concerns about withdrawal symptoms and exploring strategies to mitigate them.
Nurse Clarke: You need to focus more on your health at this point. The withdrawal symptoms are temporary,but the problems created by smoking can have dangerous and long-lasting impacts on your life.
Janet: Why else would I be here if I wasn't concerned about my health?I may not be as young as I used to be, but I don't want to give up on my health.
Nurse Clarke: Exactly, which is why--I don't need you to lecture me about what I already know.
Coach: When you told Janet what she needs to focus on, she felt as if you were talking down to her. You missed an opportunity to take her concerns about withdrawal symptoms seriously.
Janet: It's kinda like you're not listening to me...
Janet: Also, I'm still worried about getting... you know ... fat.
Nurse Clarke: While you may gain some weight, the benefits of quitting smoking would be worth it.
Janet: I know that, but you didn't see what happened to my friend Susie when she tried to quit.Blew up like a blimp and kept it.
Nurse Clarke: You're worried you'll put on weight like your friend.
Janet: Yeah, poor Susie.... she was so stressed from the weight gain, she started smoking again.
Coach: When you tried to persuade Janet to overlook the challenges, she felt that you weren't taking her concerns seriously. Instead, consider exploring her concerns and challenges regarding quitting and her ideas for addressing them.
Nurse Clarke: I have some information about weight gain after quitting smoking that I can share, if you like?
Janet: Sure.
Nurse Clarke: There is a chance you'll gain some weight, that's true.Though the average person who quits smoking only gains around 5-10 pounds. How do you feel about that?
Janet: Oh... that's not so bad. I thought I'd need to buy a whole new wardrobe.
Coach: Good! You asked permission before sharing information with Janet. She felt like her opinion was being taken into account and she was more receptive to hearing what you said.
Nurse Clarke: Even if you gain weight, the exercise you've been doing could help you lose those pounds.And exercise is something you've been able to keep up and even enjoy!
Janet: Right. Hmmm.
Coach: Great! You affirmed the specific efforts Janet has already made for her health.
Janet: I guess there's a few solutions out there.... But... I just...
Janet: UGH... I JUST can't concentrate on any of this right now.I feel like-- I don't know. I hear you... but I need more time to think.
Nurse Clarke: You've got a lot going on so it's hard to focus,even though you might be interested in learning more about quitting later on.
Janet: You got that right.
Nurse Clarke: Tell me more about what in particular is making it so tough right now.
Janet: This exhibit... I'm excited for it... but... it's getting to me. You know how it goes.The second you have everything handled, something else pops up. The gallery asked me to reschedule after I already sent the invitations...it's really just not the right time to kick bad habits.
Nurse Clarke: I'd love to summarize what we talked about so far before you go.If I understood you correctly you're concerned about your chest pains and heart disease,and their connection to smoking.
Nurse Clarke: It ties back to seeing your friend get sick which makes you worry.
Nurse Clarke: So much so that you're willing to talk about quitting smoking, just not right now because of your upcoming art show.
Janet: That sounds right to me.
Nurse Clarke: Great. Is there anything else you'd like to discuss today?
Janet: No... I think I'm good.
Nurse Clarke: When would be a good time for you to return to talk some more about options for quitting smoking?
Janet: Well, the exhibit is in six weeks. The earliest I could come back here would be... two months from now.
Nurse Clarke: That would be great! Why don't you make an appointment on the way out?
Janet: OK. I'll be back... probably... eventually. Wish me luck in the meantime!
Nurse Clarke: Of course. Good luck with your exhibit!
Coach: Great! You chose to summarize what the two of you discussed today even though Janet wasn't ready to talk about smoking cessation yet. This allows her to confirm that you understood her correctly and gives her a chance to add anything important that wasn't mentioned.
Coach: Two months later, Janet returns for another visit...
Nurse Clarke: Hi Janet . Glad you came back to talk again.
Janet: Our last conversation stuck with me I guess, and since my schedule cleared up,I've had a lot more headspace to... well, let's get started.
Coach: Janet's return for this visit suggests she has been thinking seriously about her smoking. Now is a good time to find out more about her ideas, feelings and preferences about quitting.
Nurse Clarke: Let's set you up with our VA smoking specialist today.
Janet: Today?
Nurse Clarke: Our smoking cessation expert can guide you through all the ways the VA can help.
Janet: I'd rather just talk with you about it first if that's alright.
Nurse Clarke: Sure. I can go over some smoking cessation options.
Coach: Janet is expressing ambivalence about committing to a plan for quitting. Consider exploring her motivation as well as her experiences and preferences regarding change. It may be more effective to have used the Importance Scale first. Remember, undoing is an option.
Coach: Janet is expressing ambivalence about committing to a plan for quitting. Consider exploring her motivation as well as her experiences and preferences regarding change.
Janet: I'd like to know what these magic solutions are you think I haven't tried, but so we're clear,I don't know if I'm ready to commit to anything today, or at all for that matter.
Nurse Clarke: Sure. I'll take you through some quitting techniques we support here at the VA:counselling, medications, behavioral strategies. And while they each help in different ways,we find patients have the most success when they combine the strategies.
Nurse Clarke: Let's discuss how you can prepare to quit smoking.
Janet: I told you - I don't know that I want to quit right now.
Nurse Clarke: This isn't about quitting now. It's about planning how you're going to quit later.
Janet: I'm not ready to plan like that. I'll figure that out on my own.
Coach: Janet isn't ready to discuss a specific plan. Consider ways to explore her needs and preferences--it will save you time and effort!
Nurse Clarke: Counseling seems like it could be right for you.
Janet: Oh yeah? ...why?
Nurse Clarke: Well, you might benefit from having a person who understands what you're going through to talk to about all this.
Janet: I don't think some VA counselor is going to understand what I'm "going through."I stopped drinking without one, and I don't need one now.
Coach: Your suggestion was well-intentioned, though, Janet is not very receptive to being told what would be right for her. Instead, consider gauging her interest in hearing more about counseling.
Nurse Clarke: You mentioned that you struggled with withdrawal symptoms whenever you try to quit.For that we recommend specific medications, things you mentioned trying like gums,lozenges, and patches. How did that work for you?
Janet: The short answer? It didn't. I've been smoking since the Navy, too long for quick-fixes.
Nurse Clarke: What do you mean?
Janet: I'm not some schoolkid smoking clove cigarettes behind the dumpster. I smoke over a pack a day.The gum was good for a quick craving, but it didn't get me close to the finish line.
Coach: Good! You chose to ask an open-ended question and Janet shared her experience with medications for withdrawal symptoms and her understanding of their potential effectiveness for her.
Nurse Clarke: Tell me more about that.
Janet: That's all there is to tell.
Nurse Clarke: You said the gum was good for a quick craving. In what way?
Janet: I just noticed that, compared to the other times I've tried quitting, I didn't... it wasn't as extreme. You know?Like, the spikes when I needed a cigarette. It's not like it kept me smoke-free for good.
Coach: Good choice! Exploring Janet's experience of the week she noted some benefit may help you and her build on previous success.
Nurse Clarke: They might have worked better combined with other quitting methods, but it sounds like they did help a little.
Coach: Though the information was accurate, it felt like advice to Janet, who pushed back a bit. As a result, the accurate reflection about the meds helping had limited impact.
Janet: In the sense that everything helps a little, yes, I suppose so.
Nurse Clarke: Well you don't have to settle on anything now, but it can't hurt to have ideas if you decide to move forward.
Janet: Right. I'll tuck that away in my back pocket if I decide to try quitting again.
Nurse Clarke: Moving forward, which of the things we discussed do you want to try?
Janet: Huh? I need to process it all. That's... I don't know.
Coach: After hearing about so many options, Janet may feel overwhelmed. Instead of asking her for commitment, consider sharing info in small chunks and exploring her interest in learning more.
Janet: To tell the truth, I wasn't actually planning on coming back after our last visit, but... my grandkids...a few days after my show, I found a pack of cigarettes in their toybox at my house...so I asked them about it, they said they were hiding it from me.I think they look at me like I'm helpless.
Nurse Clarke: But you want to find a way to change that... be their role model.
Janet: Yeah... I do.
Janet: I'm not sure meeting with this smoking expert here at the VA is necessary.But I might try quitting another time on my own.
Nurse Clarke: We can absolutely support you with that decision.
Nurse Clarke: I think we made good progress today.
Janet: "Making progress" wasn't really my agenda today, but sure.
Nurse Clarke: I only mean that you're leaving a lot closer to quitting than when you came in.
Janet: I guess that's true.
Nurse Clarke: You can pick up some resources for quitting at the front desk. We'll touch base again soon. Good luck with everything.
Janet: Thanks.
Coach: At her next visit, Janet reported that she was still smoking and hadn't made any efforts to reduce or quit.
Nurse Clarke: Hello Ms. Lopez. Our last chat was six months ago. It's good to see you again!
Janet: Good to see you too, Nurse Clarke.
Nurse Clarke: Ok so... you've just seen the doctor....your blood pressure is good,and your recent blood work looks good. How are you doing?
Janet: I'm doing just fine. That said, I'm ... I'm a busy lady.
Nurse Clarke: No problem, we'll keep this as short as possible.
Nurse Clarke: How have you been lately?
Janet: I have another exhibit coming up - it's taking up most of my time lately...
Nurse Clarke: Art, right? Painting?
Janet: That's it.
Nurse Clarke: I can imagine that putting something together like that takes a lot of energy and focus.
Janet: Yes... But I... fit in a little exercise when I can like we talked about last time...Something's better than nothing, right?
Nurse Clarke: So how's the art exhibit going?
Janet: Ok, I guess. Just this week I've been getting my website together, figuring out spacing things with the gallery,and I wasn't happy with how the postcards turned out so I've been back and forthing with the designer...I'm sorry, I'm rambling. Boring details. We can talk about something else.
Nurse Clarke: Not boring at all... but if you like, we can switch topics.
Coach: Nice! When you asked about the exhibit, Janet felt like you had a genuine interest in her and her well-being.
Janet: I'm just happy I've managed to exercise as much as I have.
Nurse Clarke: Nice to hear you're keeping up the exercise. How's it been going?
Janet: Not half-bad! I walk along the beach and chat on the phone with my friend Margaret.
Nurse Clarke: Walking is a wonderful way to keep in shape without taxing the body too much.And you've incorporated a fun way to enjoy yourself in the process.
Janet: Right. I get my walk in and I get to catch up with my friends.And I'm happy to keep doing it, especially since walking doesn't take up too much time...
Coach: Great job! Janet appreciated that you reaffirmed her efforts to stay healthy, especially since her schedule is so busy
Janet: I got other priorities, too.
Janet: Like I'm thinking about taking my family on a trip,but I'm wondering if given my health it might be a little too much for me.Not to mention travelling just isn't as cheap as it was in my day.
Nurse Clarke: You're wondering if travelling abroad is a good idea considering your health issues,and you're concerned about the expense.
Janet: Yeah. I mean, walking on the beach near my house is easy on the old lungs. And doesn't cost me anything to get there...
Janet: But... I see the beach every day. Heck, maybe a bit of fresh air might even be good for my health.And it'd sure be nice to take my family somewhere new.I did the math and if I booked a trip I wouldn't have the budget for my smokes for like... six months.
Coach: Good job! You used a reflection to show your interest in Janet's perspective and she continued to share how her desire to travel relates to her health and smoking.
Janet: But look - weren't we here to ... to talk about my health?
Nurse Clarke: What can you tell me about your health these days?
Janet: Well, I still get chest pains, like we chatted about last time.
Coach: Nice! Your open-ended question let Janet go into detail about one of her main concerns: her chest pain.
Janet: Doesn't feel like I'm about to have a... heart attack or anything. Doesn't make 'em any less annoying though.
Nurse Clarke: When have you been noticing the chest pains? Any times different from our previous session?
Janet: Eh, they've stayed pretty consistent since last time. Still only notice 'em when I'm stressed.Or sometimes if my grandkids try to get me to run around.Or... I guess I notice it sometimes when it's cold out, or I'm walking up the hill near my house.Just the... price of doing what you enjoy, I suppose
Nurse Clarke: So, what's your understanding of the connection between smoking and chest pain?
Janet: I know that smoking affects your heart and can lead to heart attacks.It just that sometimes, even after I have chest pain, I still want a smoke.
Nurse Clarke: So for you, the connection works both ways.
Coach: Good! You asked Janet to share her understanding and she answered in an honest and open way.
Nurse Clarke: And how do you feel about smoking?
Janet: I mean, I've been smoking my whole life. I'm at a pack a day - and I enjoy it.I know stopping would be better for my health, but I don't have time to quit right now.
Nurse Clarke: You've been a smoker for a long time and you are not sure you have time to quit right now,THOUGH you know that quitting could improve your chest pains,reduce your risk of a heart attack or stroke and make a real difference in your health.
Janet: I mean, yes I know if I cut down I'd probably reduce the coughing and the chest pains.But I just don't know how realistic me quitting at this age would be. Even with any other... benefits...
Coach: Great job! You used a double-sided reflection that first acknowledged Janet's ambivalence and then reflected and affirmed Janet's knowledge of the connection between smoking and chest pain.
Nurse Clarke: Like saving money to use for something else...
Janet: Yeah, exactly.
Coach: Great! You remembered and reflected an important reason for staying healthy that Janet shared with you, which sparked change talk!
Janet: Having a little more money in the pocket couldn't hurt.There's a lot of the world to see and I'd love to have enough money to help my family see it.And even if I'm not in the best health, maybe some travel will be good for me.Only thing.... trips are expensive. And cigarettes aren't cheap.
Janet: Don't get me wrong, I have tried quitting a bunch of times in the past. But nothing worked.The patch gave me a rash. Cold turkey just made ME feel like a turkey when I started smoking again two days later.I tried the gum, too. Felt nice to be chewing something, I guess.Lasted a couple of days, but it didn't do it for me.
Nurse Clarke: Even though it wasn't permanent, you had some success with quitting smoking in the past.
Janet: Success? The most I ever made it without having a cigarette was like two days..
Coach: Good! You affirmed Janet's past efforts and she shared more about her experience, even though she wasn't particularly receptive to considering her past attempts as successful.
Nurse Clarke: Sounds frustrating. The good thing is, your past attempts to quit can actually serve as opportunities for learning.
Janet: Learning what? How not to quit?
Nurse Clarke: Sort of! You learned what doesn't work at all, compared to where you had a little success.
Janet: OK, maybe some people can learn from FAILING to quit smoking, but I'm not "some people".I'm not sure learned I anything from MY experience.
Nurse Clarke: Well, you managed to stay cigarette-free for two whole days...at a pack a day, thats forty cigarettes you didn't smoke!
Janet: I was pretty miserable....though I get what you are saying. I was determined ....I guess that's a positive.
Nurse Clarke: It is.
Coach: Great! Instead of disagreeing with Janet's assessment of her past attempts, you've reframed them as contributing to her future success.
Janet: It's just... quitting is already hard to even think about.So to actually do it again and deal with all the other crap that happens to your body?Please. I do not need that in my life
Nurse Clarke: Tell me about the challenges you faced quitting in the past.
Coach: Great! By exploring Janet's challenges in an open-ended manner, you're taking her concerns seriously while also identifying circumstances and symptoms that may be addressable.
Janet: I suppose the biggest one was I would get... cranky.Like Frankenstein cranky. And I'm supposed to be the nice grandma! You seem nice enough to me! ...Besides getting cranky, were there any other issues you were concerned about?
Janet: Well, not to be superficial or anything, but I really don't want to get, well... fat.It ain't easy for a lady to lose weight at this age, you know.
Nurse Clarke: Tell me more about how you're concerned you'll gain weight.
Janet: Well, I've never quit long enough to experience it myself.But my pal Susie managed for about a month. Blew up like a blimp and kept it.
Nurse Clarke: You're worried when you quit smoking you'll put on a significant amount of weight,and have difficulty losing it afterwards.
Janet: Yeah, poor Susie.... she was so stressed from the weight gain, she started smoking again.
Coach: Great! By asking Janet to tell you more about how she's concerned she'll gain weight, you showed you're taking her concerns seriously.
Nurse Clarke: I have some information about weight gain after quitting smoking that I can share, if you like?
Janet: Sure.
Nurse Clarke: There is a chance you'll gain some weight, that's true.Though the average person who quits smoking only gains around 5-10 pounds. How do you feel about that?
Janet: Oh... that's not so bad. I thought I'd need to buy a whole new wardrobe.
Coach: Good! You asked permission before sharing information with Janet. She felt like her opinion was being taken into account and she was more receptive to hearing what you said.
Nurse Clarke: Even if you gain weight, the exercise you've been doing could help you lose those pounds.And exercise is something you've been able to keep up and even enjoy!
Janet: Right. Hmmm.
Coach: Great! You affirmed the specific efforts Janet has already made for her health.
Janet: Something to think about, I guess.
Janet: What about me becoming a grinch? And all that other junk that'll happen to my body?
Nurse Clarke: What other withdrawal symptoms have you experienced in the past?
Janet: Well, besides getting cranky, my hands shake, which makes it hard to paint.And after a long day of not smoking and not painting, I end up not sleeping.Which makes it even harder to concentrate on anything the next day.
Coach: Great! You asked an open-ended question to learn more about Janet's specific experience with withdrawal symptoms and how they impacted her life. This allows you to discuss options that may address her specific concerns.
Nurse Clarke: So in the past when you've tried to quit, you've found you get cranky,your hands shake and you have trouble sleeping. Which all makes it difficult to focus.
Janet: Yeah.
Nurse Clarke: Those symptoms are common nicotine withdrawal symptoms experienced by many people when they quit smoking.
Janet: Great. I don't take a lot of pleasure in being in the majority.
Nurse Clarke: The good news is, these symptoms will become less severe over time.The first few days are the hardest, and for most people withdrawal symptoms resolve within a couple of weeks.
Janet: Hmm, I don't know about 'good' news. But I guess you could say it's 'not terrible' news...
Coach: Good choice! The accurate reflection of Janet's experience and subsequent explanation is a first step in partnering with her to address this important barrier.
Nurse Clarke: How have you dealt with your withdrawal symptoms in the past?
Janet: Mainly just what I mentioned earlier, the patch, the gum...
Nurse Clarke: And what's your understanding of other options to help quit?
Janet: Well, I know there's fancy medicines these days, including inhaler thingees...
Janet: I guess there's a few solutions out there.... But... I just...
Janet: UGH... I JUST can't concentrate on any of this right now.I feel like-- I don't know. I hear you... but I need more time to think.
Nurse Clarke: Tell me more about what in particular is making it so tough right now.
Janet: This exhibit... I'm excited for it... but... it's getting to me. You know how it goes.The second you have everything handled, something else pops up. The gallery asked me to reschedule after I already sent the invitations...it's really just not the right time to kick bad habits.
Janet: I don't know how I let it all get to me like this. I mean, I've been through some stuff.
Nurse Clarke: You feel like you've managed stress better before.
Janet: Yeah. As in... this isn't the first time I've had to... I used to enjoy my margaritas. A lot...Not just happy hour, if you know what I mean. So like we talked about on the previous visit,when my husband died, I had to raise my kids solo... I thought I was okay at first, but...When my mother had to take the kids for a few days, I was like, "Janet, no, you are not okay."...It wasn't easy. But it also wasn't... that hard? I know I didn't feel like... this.
Coach: Great! You used a reflection and Janet felt comfortable sharing more with you about how she managed stress in the past, offering you opportunities to further explore strengths and successes.
Nurse Clarke: It must have been incredibly hard to lose your husband, and at such a young age.And then to raise your children alone was a huge burden. So to then kick a bad habit that you liked, on top of that...
Janet: Yeah. I mean I enjoyed my drinks - almost as much as I enjoy smoking. But I mean, I had to stop.It just.. it hurt too hard not to. Took a couple of tries...but I figured out a few things to help keep my mind off of it.Had fruit-flavored seltzer drinks as a replacement, ate a bit healthier...Look, if you don't mind, this topic's kind of heavy. I don't really wanna talk more about this right now.
Nurse Clarke: It shows amazing strength that you were able to quitsuch an addictive habit with everything else going on in your life.And of course we can talk more about this another time.
Janet: Yeah. After my art show it might be a different story.
Coach: Great! You expressed empathy by reflecting and validating Janet's challenges and affirmed her strengths, which evoked change talk about the behaviors Janet successfully applied to quitting alcohol in the past.
Nurse Clarke: All the stress of the art exhibit and its unknowns have made it tough to talk about smoking cessation options.Though if the timing were different, it might be something you'd be open to.
Janet: Exactly, at some point down the road, just not now.
Nurse Clarke: That's totally OK. Always ready to talk.
Janet: Thanks... I appreciate it. You've given me something to think about.I might even chat to my family a little more before then, see what they have to say.
Nurse Clarke: I think that's a great plan.
Coach: Great job! You used a double-sided reflection to acknowledge Janet's current ambivalence about discussing smoking cessation while also highlighting the her change talk. Janet appreciates that you're not trying to push her to do something she's not ready to do.
Nurse Clarke: I'd love to summarize what we talked about so far before you go.If I understood you correctly you're concerned about your chest pains and heart disease,and their connection to smoking.
Nurse Clarke: You wish you could quit because you want to save up for that vacation with your family.
Nurse Clarke: So much so that you're willing to talk about quitting smoking, just not right now because of your upcoming art show.
Janet: That sounds right to me.
Nurse Clarke: Great. Is there anything else you'd like to discuss today?
Janet: No... I think I'm good.
Nurse Clarke: When would be a good time for you to return to talk some more about options for quitting smoking?
Janet: Well, the exhibit is in six weeks. The earliest I could come back here would be... two months from now.
Nurse Clarke: That would be great! Why don't you make an appointment on the way out?
Janet: OK. I'll be back... probably... eventually. Wish me luck in the meantime!
Nurse Clarke: Of course. Good luck with your exhibit!
Coach: Great! You chose to summarize what the two of you discussed today even though Janet wasn't ready to talk about smoking cessation yet. This allows her to confirm that you understood her correctly and gives her a chance to add anything important that wasn't mentioned.
Coach: Two months later, Janet returns for another visit...
Nurse Clarke: Hi Janet . Glad you came back to talk again.
Janet: Our last conversation stuck with me I guess, and since my schedule cleared up,I've had a lot more headspace to... well, let's get started.
Coach: Janet's return for this visit suggests she has been thinking seriously about her smoking. Now is a good time to find out more about her ideas, feelings and preferences about quitting.
Nurse Clarke: What are you hoping to accomplish today?
Janet: I'm trying to see what quitting would look like for me... I guess I just want to see what's out there,see if there's anything I'm missing that could help me get past the usual roadblocks.
Nurse Clarke: I'm glad to hear you're interested in getting some help, addressing some concerns.I am happy to explore options with you.
Janet: Perfect.
Coach: Great! By asking Janet what she'd like to accomplish, you empowered her to consider and share her goals as well as some concerns she would like help with.
Nurse Clarke: On a scale from 0 to 10, how important is it for you to quit?With zero being not important at all, and 10 being very important.
Coach: Great choice. Using the importance scale with Janet will help you gauge her current motivation, providing opportunity for further exploration.
Janet: I'm still going back and forth honestly. I'd probably go with a 4.
Nurse Clarke: What made you say that number and not something lower...
Coach: Nice job! Asking what made her choose that number instead of a lower one is a great way to elicit her motivations.
Nurse Clarke: ...like a 3 for example?
Janet: I've tried so many times- it's hard, but... let me put it this way-
Janet: ...my mom always told stories of Puerto Vallarta, but I barely remember it.If I could spend less on cigarettes, I might be able to save up for a small trip,show my grandkids where they come from... 'specially with how expensive cartons are getting nowadays...
Nurse Clarke: It's important to save money for the things you care about like travelling.
Janet: Exactly. Every dollar I spend on cigarettes is a dollar I could spend on something really meaningful.
Coach: Your reflection made Janet feel heard. You also emphasized an important reason for change -- saving money for travel.
Nurse Clarke: How would you feel about going over some smoking cessation options like you mentioned at the end of our last visit?...should you choose to go that route.
Coach: Excellent! Janet appreciated that you first asked for permission before sharing information.
Coach: Excellent! Janet appreciated that you first asked for permission before sharing information. However, it may be more effective to use the Importance Scale first. Remember, undoing is an option.
Janet: Well, I want to. But I'm just having a hard time with, I don't know, the point of it all.I'm not a young woman anymore.I'd love to feel better, but by the time I'd see any health benefits, I'd probably be long gone.
Nurse Clarke: Can I share some of the immediate health benefits you can get from quitting?Things you might notice much sooner than you'd think.
Janet: Immediate benefits? I thought it was just ... quit before it's too late and you're in the ground. Not exactly.
Coach: Nice! Janet appreciated that you first asked for permission before sharing information.
Janet: Well I've tried quitting before and it's not like I suddenly started painting better.It's just feels like so much... work. What would quitting do for me?
Nurse Clarke: Within one year of quitting, you could notice clearer and deeper breathing,reduced chance of lung infection, and less shortness of breath.
Janet: Oh... I- I guess I feel like my breathing is fine? Then again, that could have helped me last weekend.I had to sit down halfway through my art show because I was out of breath.
Janet: I'd like to know what these magic solutions are you think I haven't tried, but so we're clear,I don't know if I'm ready to commit to anything today, or at all for that matter.
Nurse Clarke: Sure. I'll take you through some quitting techniques we support here at the VA:counselling, medications, behavioral strategies. And while they each help in different ways,we find patients have the most success when they combine the strategies.
Nurse Clarke: What strategies do you want to talk about first? They can be the ones I named, or something different...
Janet: I didn't come in here today with a plan in mind. I only know what's helped in the past and what definitely hasn't.
Nurse Clarke: Which things are the ones you think might help?
Janet: Hm... I've quit a dozen times before, but I never follow through. So I guess anything that might help me stick with it.
Nurse Clarke: You're not positive what's going to help, but you'd like to explore strategies that help with follow-through.
Janet: Exactly.
Coach: Asking Janet about the strategies that she prefers to discuss supports her autonomy and may increase her receptiveness to the strategies that you might share.
Nurse Clarke: If you're looking for continued support, I could tell you a little about counseling.
Coach: Good choice! You offered an opportunity to learn more about counseling.
Nurse Clarke: To put it in your words, someone to help you "stick with it" if you start to slip.We have resources like that here at the VA.
Coach: Good choice! You offered an opportunity to learn more about counseling. Nurse Clarke's use of Janet's own words further enhanced this approach.
Janet: I remember people telling me about group therapy programs when I stopped drinking.I see the benefit, but- but I never tried it myself. It all felt too... public. Not this grandma...
Nurse Clarke: I've known patients who had a lot of success with more private solutionslike quitlines you can call and even text message.
Janet: That's not so public... but I barely use my cell phone as it is.
Nurse Clarke: There are services that do private in-person sessions as well.
Janet: Okay... that would address my issue with the group thing... something to think about....I know a lot about counselling already, so let's just move on.
Nurse Clarke: Fine with me.
Coach: Good choice! You shared information that was tailored to Janet's preferences and needs, which increased her receptiveness and evoked some change talk.
Nurse Clarke: What do you know about behavioral strategies for quitting?
Coach: Good choice. Continue to explore Janet's understanding of behavioral strategies.
Janet: Isn't the behavior "stop smoking"? I don't know what you mean.
Nurse Clarke: Like specific actions you can take to set yourself up for success.
Janet: Everyone is always telling me to quit right away. I've never really taken much time to "set up" quitting."No time like the present." That's what my son tells me when it comes up but...it's never the right time, like before, with my art show. It's too stressful.
Nurse Clarke: Trying to quit right away can be stressful, but there are actually lots of benefits to preparing instead of diving in.Can I share some of those with you?
Janet: Go ahead.
Nurse Clarke: There are things you can do to reduce the stress of quitting, like...hiding or throwing away your cigarettes or your ashtrays or other reminders of smoking...And you can think about how you'll respond when you do encounter triggers before it happens.
Janet: Huh. I've never tried that. Usually someone gets me all worked up,I quit right then and there, and I'm smoking again by dinner.
Coach: Good! You asked permission before sharing information. The more Janet participates in the planning, the more receptive and motivated she is likely to be.
Nurse Clarke: Now that we've talked a little about it, how do you feel about the idea of preparing to quit ahead of time?
Janet: Well it's definitely a different strategy than I've heard before- you know, the usual stuff for nicotine cravings.
Nurse Clarke: In what way?
Janet: It's not just handling symptoms. It kind of helps with the planning part too.It's interesting; that's all. I'll think about it.
Coach: Good choice to ask about interest in taking steps to prepare for quitting!
Nurse Clarke: How would you feel talking about something you could do during the actual quitting process?Not a quit day, but something more concrete.
Janet: I think I'd like that a lot. That's more what I was looking for when I came in today.
Coach: Great idea to ask permission to support Janet's autonomy and honor her preferences!
Nurse Clarke: You mentioned that you struggled with withdrawal symptoms whenever you try to quit.For that we recommend specific medications, things you mentioned trying like gums,lozenges, and patches. How did that work for you?
Janet: The short answer? It didn't. I've been smoking since the Navy, too long for quick-fixes.
Nurse Clarke: What do you mean?
Janet: I'm not some schoolkid smoking clove cigarettes behind the dumpster. I smoke over a pack a day.The gum was good for a quick craving, but it didn't get me close to the finish line.
Coach: Good! You chose to ask an open-ended question and Janet shared her experience with medications for withdrawal symptoms and her understanding of their potential effectiveness for her.
Nurse Clarke: Tell me more about that.
Janet: That's all there is to tell.
Nurse Clarke: You said the gum was good for a quick craving. In what way?
Janet: I just noticed that, compared to the other times I've tried quitting, I didn't... it wasn't as extreme. You know?Like, the spikes when I needed a cigarette. It's not like it kept me smoke-free for good.
Coach: Good choice! Exploring Janet's experience of the week she noted some benefit may help you and her build on previous success.
Nurse Clarke: Would it be okay if I shared how medications like gum work when paired with some other strategies?
Janet: Can you explain what you mean?
Nurse Clarke: Nicotine replacement products mostly work to reduce withdrawal symptoms like shakiness or irritability.The idea is to reduce those symptoms so it's easier to follow through with other quitting strategies.
Janet: That would have been great - but that's not what happened.
Nurse Clarke: Maybe you weren't getting enough nicotine. Our pharmacists could help you sort out a more effective dosage.
Janet: I'll think about it.
Coach: Good job! You asked Janet's permission to continue to share information and tailored your comments to address her needs. As a result, she expressed some interest in this option. You are making progress.
Nurse Clarke: To summarize what we talked about, you might be interested in some of these quitting strategies.
Coach: Great choice! A summary provides an opportunity to reflect interest and motivation and to transition towards collaborating on a specific plan.
Nurse Clarke: In-person counseling sounds appealing.
Nurse Clarke: Medication to help with cravings, for example.
Nurse Clarke: ...and planning ways to manage your smoking triggers.
Nurse Clarke: It's especially great that you're willing to consider all three together.We've found patients have had the most success when the combine strategies.
Janet: There's more to it than I realized...
Nurse Clarke: Than you realized? What do you mean?
Janet: To tell the truth, I wasn't actually planning on coming back after our last visit, but... my grandkids...a few days after my show, I found a pack of cigarettes in their toybox at my house...so I asked them about it, they said they were hiding it from me.I think they look at me like I'm helpless.
Nurse Clarke: But you want to find a way to change that... be their role model.
Janet: Yeah... I do.
Janet: In case I do decide I want to talk to the VA smoking person, I was wondering if you could tell me what that might look like.
Nurse Clarke: We can absolutely support you with that decision.
Nurse Clarke: I think it's great you're thinking about diving in right away.The planning process usually starts with setting something we call SMART goals. Can I tell you about those?
Janet: Please do.
Nurse Clarke: SMART goals are smaller benchmarks that we can set towards the bigger goal of quitting smoking.They should be specific, measurable, action-oriented, realistic, and time-based- smart!Basically, you want to pick something you can realistically achieve.
Janet: Like quitting permanently?
Coach: Great work! Janet appreciated that you asked for permission before sharing information about SMART goals.
Nurse Clarke: Quitting permanently is a great long term objective and challenge.For a SMART goal, we might want to consider setting something smaller and more achievable.
Janet: Okay that sounds better. How about...
Coach: Great! You first affirmed Janet's motivation to quit and then prompted her to think about smaller action steps. Now she has a SMART goal!
Janet: ...scheduling the actual meeting with the VA smoking person.
Nurse Clarke: That sounds perfect! When do you think you could do that?
Janet: I can probably make that happen this Friday. I don't have any deadlines coming up or anything.
Nurse Clarke: Wonderful.
Nurse Clarke: How confident are you that you'll reach your goal on a scale of zero to ten;zero being not at all confident and ten being extremely confident?
Coach: Good job! Using this scale gave Janet the space to honestly gauge her confidence in achieving her goal.
Janet: Uh... six.
Nurse Clarke: What made you say that and not a lower number? Like a 4.
Janet: I think just... what you were saying... like considering those strategies. I feel like I know what I'm getting myself into. You know?
Coach: Nice! You helped Janet reflect on the strengths that led her to choose that number.
Janet: I've heard a lot of this stuff that we talked about before, but I think I have a better handle on it now.
Nurse Clarke: What would make you say an even higher number like a 9?
Janet: Hmmm... I don't know. I guess I still have a few concerns, like... since my last visit, actually,I've noticed more than ever how smoking is a part of my daily life...
Coach: Asking what would make confidence higher helps to identify barriers that may interfere with reaching goals. Once barriers are revealed, you can explore options for addressing them.
Janet: ...in the lead up to my show, I realized I use smoking as a sort of ...reward for crossing something off my list.I'll spend hours on a single piece of art. The promise of a cigarette at the end of the tunnel motivates me to finish.
Nurse Clarke: What alternatives can you think of?
Coach: Good job putting Janet at the center of brainstorming solutions. She'll feel more ownership of a plan she helped come up with!
Janet: Like candy instead of smoking? Great. Instead of dying of lung cancer, I'll die of diabetes.
Nurse Clarke: It doesn't have to be something like that.
Janet: I know... it could be something like watching TV, but that's so... "involved".The cigarettes are easy, and they don't pull me out of the zone.
Nurse Clarke: You want a simple smoking replacement that doesn't change your routine.
Janet: Hm... you know a friend just gave me one of those puzzle books- crosswords, sudoku, stuff like that.
Coach: Great job responding to barriers with a reflection that prompted Janet to identify a potential solution.
Janet: It's better than watching TV. That's for sure. And it'll still feel like a treat...
Nurse Clarke: Great.
Nurse Clarke: You're working hard to take steps to better your health,and everyone here at the VA wants to support you however we can.
Janet: I've worked hard for fifty-six years, raised two kids all on my own... I'm not afraid of a little hard work.
Nurse Clarke: It's hard work, but it's important work, which is why it's so significant you came back to talk today.We'll meet again soon to keep up with your cardiovascular health.
Janet: I appreciate it. Thanks again... for everything!
Coach: After this visit, Janet spoke with a smoking cessation counselor. They discussed her preference for nicotine gum, and about going to one-on-one sessions. She set a quit day on her grandkids' birthday and at her next visit she reported that she hadn't smoked for 30 days.
Nurse Clarke: Hello Ms. Lopez. Our last chat was six months ago. It's good to see you again!
Janet: Good to see you too, Nurse Clarke.
Nurse Clarke: Ok so... you've just seen the doctor....your blood pressure is good,and your recent blood work looks good. How are you doing?
Janet: I'm doing just fine. That said, I'm ... I'm a busy lady.
Nurse Clarke: No problem, we'll keep this as short as possible.
Nurse Clarke: Let's talk about how you're doing with the chest pains we discussed last time...
Janet: I still have them. And they're not getting any better.
Coach: By choosing the agenda, you miss an opportunity to explore what's important to Janet. Instead, you can try asking open-ended questions about Janet's agenda for the visit and her concerns.
Janet: Doesn't feel like I'm about to have a... heart attack or anything. Doesn't make 'em any less annoying though.
Nurse Clarke: When have you been noticing the chest pains? Any times different from our previous session?
Janet: Eh, they've stayed pretty consistent since last time. Still only notice 'em when I'm stressed.Or sometimes if my grandkids try to get me to run around.Or... I guess I notice it sometimes when it's cold out, or I'm walking up the hill near my house.Just the... price of doing what you enjoy, I suppose
Nurse Clarke: Smoking causes heart disease, and heart disease causes chest pains.
Janet: Well, I'm not an idiot. I know that.And for the record sometimes I want to have a smoke after the chest pains, just to get a little relief.
Nurse Clarke: So for you, the connection works both ways.
Coach: When you shared information without asking permission or asking what Janet knew, she felt belittled and pushed back. Next time, try exploring what she knows about the connection between smoking and chest pains.
Nurse Clarke: And how do you feel about smoking?
Janet: I mean, I've been smoking my whole life. I'm at a pack a day - and I enjoy it.I know stopping would be better for my health, but I don't have time to quit right now.
Nurse Clarke: Well, when WOULD be a good time to quit?
Janet: I don't know... but... just... not NOW.
Coach: Though you asked an open question, it was a challenging one. Consider using reflections to respond to her concerns and her 'change talk' and further explore her motivation.
Nurse Clarke: Since you recognize the damage smoking causes, maybe you should consider quitting smoking.
Janet: Yeah, but I also recognize 'should' and 'could' are not the same thing:just because it's better for me, doesn't make it any easier to contemplate, let alone do.
Nurse Clarke: Quitting is difficult to even think about right now, while at the same time,you know that you'd be in better health if you did quit.
Janet: I mean, yes in that I know if I had never smoked I probably wouldn't have these health issues to begin with.And... well, I suppose there would be some other... benefits...
Coach: Instead of suggesting quitting, consider using reflections or questions to explore Janet's beliefs and motivation . Note the benefit of Nurse Clarke's subsequent reflections.
Nurse Clarke: Other benefits?
Janet: Yeah. But look... I got a lot going on right now.
Janet: I have another exhibit coming up - it's taking up most of my time lately...
Nurse Clarke: Art, right? Painting?
Janet: That's it.
Nurse Clarke: I can imagine that putting something together like that takes a lot of energy and focus.
Janet: Yes... But I... fit in a little exercise when I can like we talked about last time...Something's better than nothing, right?
Nurse Clarke: So how's the art exhibit going?
Janet: Ok, I guess. Just this week I've been getting my website together, figuring out spacing things with the gallery,and I wasn't happy with how the postcards turned out so I've been back and forthing with the designer...I'm sorry, I'm rambling. Boring details. We can talk about something else.
Nurse Clarke: Not boring at all... but if you like, we can switch topics.
Coach: Nice! When you asked about the exhibit, Janet felt like you had a genuine interest in her and her well-being.
Janet: I'm just happy I've managed to exercise as much as I have.
Nurse Clarke: A 'little' exercise is nice, but last time we discussed more than 'a little'.
Janet: I walk along the beach and chat on the phone with my friend Margaret. Seems like it does the job.
Nurse Clarke: So how often are you walking and for how long?
Janet: Eh, around half an hour. Like two or three times a week.
Nurse Clarke: Half an hour is okay, but really you should be aiming for five or more days a week.
Janet: I'm fifty-six years old. Walking three times a week is as much as I can manage.
Coach: You may be well-intentioned in telling Janet that she should be exercising more, but she felt as if you were pushing her to do something unrealistic. If you had reaffirmed the efforts Janet already made, she may feel more encouraged to continue making healthy choices.
Janet: I got other priorities, too.
Janet: Like that my health situation has been getting bigger than... just me... lately.My grandkids, for instance. They don't totally understand what's going on, like when I have chest pains, but they know something's up.
Nurse Clarke: I bet your grandkids would really like it if you eased up on the smoking.
Janet: I bet I'd really like it if you eased up on me. And my grandkids don't really even know what smoking is.
Nurse Clarke: I just meant quitting smoking may diminish some of the effects smoking has on your health.Your grandkids would notice that!
Janet: Look, I know you mean well - my relationship with my grandkids is important.
Coach: Janet felt like you were pushing her and she felt talked-down to. Try using reflections to continue to explore Janet's motivations and help her uncover the impact smoking has on her.
Nurse Clarke: So you recognize there are some other benefits to quitting smoking....
Janet: Yeah, I guess there would be some other... benefits...too
Nurse Clarke: Like saving money to use for something else...
Janet: Hmm, yeah. I guess that's kinda important... Not totally what was on my mind... but,anyway, I know there are advantages to quitting smoking. It's just... not that easy to actually do...
Coach: This was not what Janet mentioned as important to her previously. Recalling important conversation details like a patient's motivations for change can be a great way to connect with patients and remind them of their goals.
Janet: Don't get me wrong, I have tried quitting a bunch of times in the past. But nothing worked.The patch gave me a rash. Cold turkey just made ME feel like a turkey when I started smoking again two days later.I tried the gum, too. Felt nice to be chewing something, I guess.Lasted a couple of days, but it didn't do it for me.
Nurse Clarke: You've tried to quit smoking in the past and met with some obstacles.
Janet: Yeah. But we're not talking twig-in-the-road obstacles. We're talking mountains.
Coach: Though you intended to affirm Janet's past attempts, your reflection focused on the obstacles, which Janet amplified in her response. Try exploring reasons for past attempts as well as benefits and small successes.
Nurse Clarke: Sounds frustrating. The good thing is, your past attempts to quit can actually serve as opportunities for learning.
Janet: Learning what? How not to quit?
Nurse Clarke: You're concerned you'll never be able to quit.
Janet: Well, yeah. That's pretty much the whole problem.
Coach: Though you intended to affirm Janet's past attempts, your reflection focused on the obstacles, which Janet amplified in her response. Try exploring reasons for past attempts as well as benefits and small successes. Remember, undoing is an option.
Janet: It's just... quitting is already hard to even think about.So to actually do it again and deal with all the other crap that happens to your body?Please. I do not need that in my life
Nurse Clarke: It may be hard, but it will help reduce your risk of a heart attack.
Janet: I understand. But this is just a really bad time for me to do this, risk or not.
Coach: When you tried to persuade Janet to make a change, she felt like you weren't taking her concerns seriously. Instead, consider exploring her experience, beliefs, and motivation . Remember, undoing is an option.
Nurse Clarke: It's perfectly normal for your body to respond negatively at first when you quit smoking.
Janet: Well, the things that happened to my body didn't seem perfectly normal to me.
Janet: I suppose the biggest one was I would get... cranky.Like Frankenstein cranky. And I'm supposed to be the nice grandma! You seem nice enough to me! ...Besides getting cranky, were there any other issues you were concerned about?
Janet: Well, not to be superficial or anything, but I really don't want to get, well... fat.It ain't easy for a lady to lose weight at this age, you know.
Nurse Clarke: Tell me more about how you're concerned you'll gain weight.
Janet: Well, I've never quit long enough to experience it myself.But my pal Susie managed for about a month. Blew up like a blimp and kept it.
Nurse Clarke: You're worried when you quit smoking you'll put on a significant amount of weight,and have difficulty losing it afterwards.
Janet: Yeah, poor Susie.... she was so stressed from the weight gain, she started smoking again.
Coach: Great! By asking Janet to tell you more about how she's concerned she'll gain weight, you showed you're taking her concerns seriously.
Nurse Clarke: I have some information about weight gain after quitting smoking that I can share, if you like?
Janet: Sure.
Nurse Clarke: There is a chance you'll gain some weight, that's true.Though the average person who quits smoking only gains around 5-10 pounds. How do you feel about that?
Janet: Oh... that's not so bad. I thought I'd need to buy a whole new wardrobe.
Coach: Good! You asked permission before sharing information with Janet. She felt like her opinion was being taken into account and she was more receptive to hearing what you said.
Nurse Clarke: There are a lot of ways you can prevent weight gain after you quit smoking.Do you want to try brainstorming some ideas you could use?
Janet: Well, besides the walking.... I guess eating a little better couldn't hurt.
Nurse Clarke: When some people quit smoking they have increased food cravings,or substitute eating for smoking, which is why weight gain occurs sometimes.Smoking cessation counseling can help folks learn healthy ways to limit weight gain.
Janet: Well, I do like my ice cream. But I don't want to gain weight. Ummm. I s'pose a little help with this might be useful.
Coach: Good! You asked Janet to offer her own ideas to address her concern about weight gain rather than offering a solution for her. Her own solutions are more likely to work better for her.
Janet: Something to think about, I guess.
Janet: What about me becoming a grinch? And all that other junk that'll happen to my body?
Nurse Clarke: What other withdrawal symptoms have you experienced in the past?
Janet: Well, besides getting cranky, my hands shake, which makes it hard to paint.And after a long day of not smoking and not painting, I end up not sleeping.Which makes it even harder to concentrate on anything the next day.
Coach: Great! You asked an open-ended question to learn more about Janet's specific experience with withdrawal symptoms and how they impacted her life. This allows you to discuss options that may address her specific concerns.
Nurse Clarke: These are all normal symptoms you've gone through and they pass sooner than you think.
Janet: "Soon" isn't soon enough. I have deadlines to hit, friends to see, family to be with.I'm not sure I'm ready to take that kind of time off with all I have going on.
Nurse Clarke: With the smoking cessation methods that we can talk more about,you can learn some ways to manage and cope with the withdrawal symptoms.
Janet: I don't know... I've tried some of those and they don't always help enough.
Coach: Though you attempted to reassure Janet, you missed an opportunity to first show you heard what she shared with you about her experience with withdrawal symptoms. Instead you could use a reflection to show Janet you take her concerns seriously.
Nurse Clarke: There are many options to help with handling the withdrawal symptoms you've mentioned.
Janet: Like what?
Nurse Clarke: Some people use gum, nicotine patches...Yeah yeah I've tried those... Like I said earlier, they didn't do a lot for me... I don't know...
Coach: Though you mentioned some options and gave Janet a chance to ask you about them, you missed an opportunity to ask about her experience and knowledge of options to handle withdrawal symptoms.
Coach: Earlier, Janet mentioned that gum and nicotine patches didn't work for her. She felt like you weren't listening to her. You missed an opportunity to ask more about her experience and knowledge of options to handle withdrawal symptoms.
Janet: I guess there's a few solutions out there.... But... I just...
Janet: UGH... I JUST can't concentrate on any of this right now.I feel like-- I don't know. I hear you... but I need more time to think.
Nurse Clarke: You've got a lot going on so it's hard to focus,even though you might be interested in learning more about quitting later on.
Janet: You got that right.
Nurse Clarke: Tell me more about what in particular is making it so tough right now.
Janet: This exhibit... I'm excited for it... but... it's getting to me. You know how it goes.The second you have everything handled, something else pops up. The gallery asked me to reschedule after I already sent the invitations...it's really just not the right time to kick bad habits.
Janet: I don't know how I let it all get to me like this. I mean, I've been through some stuff.
Nurse Clarke: You feel like you've managed stress better before.
Janet: Yeah. As in... this isn't the first time I've had to... I used to enjoy my margaritas. A lot...Not just happy hour, if you know what I mean. So like we talked about on the previous visit,when my husband died, I had to raise my kids solo... I thought I was okay at first, but...When my mother had to take the kids for a few days, I was like, "Janet, no, you are not okay."...It wasn't easy. But it also wasn't... that hard? I know I didn't feel like... this.
Coach: Great! You used a reflection and Janet felt comfortable sharing more with you about how she managed stress in the past, offering you opportunities to further explore strengths and successes.
Nurse Clarke: It must have been incredibly hard to lose your husband, and at such a young age.And then to raise your children alone was a huge burden. So to then kick a bad habit that you liked, on top of that...
Janet: Yeah. I mean I enjoyed my drinks - almost as much as I enjoy smoking. But I mean, I had to stop.It just.. it hurt too hard not to. Took a couple of tries...but I figured out a few things to help keep my mind off of it.Had fruit-flavored seltzer drinks as a replacement, ate a bit healthier...Look, if you don't mind, this topic's kind of heavy. I don't really wanna talk more about this right now.
Nurse Clarke: It shows amazing strength that you were able to quitsuch an addictive habit with everything else going on in your life.And of course we can talk more about this another time.
Janet: Yeah. After my art show it might be a different story.
Coach: Great! You expressed empathy by reflecting and validating Janet's challenges and affirmed her strengths, which evoked change talk about the behaviors Janet successfully applied to quitting alcohol in the past.
Nurse Clarke: All the stress of the art exhibit and its unknowns have made it tough to talk about smoking cessation options.Though if the timing were different, it might be something you'd be open to.
Janet: Exactly, at some point down the road, just not now.
Nurse Clarke: That's totally OK. Always ready to talk.
Janet: Thanks... I appreciate it. You've given me something to think about.I might even chat to my family a little more before then, see what they have to say.
Nurse Clarke: I think that's a great plan.
Coach: Great job! You used a double-sided reflection to acknowledge Janet's current ambivalence about discussing smoking cessation while also highlighting the her change talk. Janet appreciates that you're not trying to push her to do something she's not ready to do.
Nurse Clarke: I don't want to hold you up while you're so busy.
Janet: Oh... okay. Uh... That's everything I guess.
Nurse Clarke: Great.
Nurse Clarke: When would be a good time for you to return to talk some more about options for quitting smoking?
Janet: Well, the exhibit is in six weeks. The earliest I could come back here would be... two months from now.
Nurse Clarke: That would be great! Why don't you make an appointment on the way out?
Janet: OK. I'll be back... probably... eventually. Wish me luck in the meantime!
Nurse Clarke: Of course. Good luck with your exhibit!
Coach: Great! You chose to summarize what the two of you discussed today even though Janet wasn't ready to talk about smoking cessation yet. This allows her to confirm that you understood her correctly and gives her a chance to add anything important that wasn't mentioned.
Coach: Two months later, Janet returns for another visit...
Nurse Clarke: Hi Janet . Glad you came back to talk again.
Janet: Our last conversation stuck with me I guess, and since my schedule cleared up,I've had a lot more headspace to... well, let's get started.
Coach: Janet's return for this visit suggests she has been thinking seriously about her smoking. Now is a good time to find out more about her ideas, feelings and preferences about quitting.
Nurse Clarke: How would you feel about going over some smoking cessation options like you mentioned at the end of our last visit?...should you choose to go that route.
Coach: Excellent! Janet appreciated that you first asked for permission before sharing information.
Coach: Excellent! Janet appreciated that you first asked for permission before sharing information. However, it may be more effective to use the Importance Scale first. Remember, undoing is an option.
Janet: Well, I want to. But I'm just having a hard time with, I don't know, the point of it all.I'm not a young woman anymore.I'd love to feel better, but by the time I'd see any health benefits, I'd probably be long gone.
Nurse Clarke: You're only in your fifties. There's still plenty of time to make a lasting change.
Janet: Thank you, but I don't need it sugar-coated.I've smoked for decades and I know what it's done to my body. Let's just get on with it.
Coach: Telling Janet there's 'plenty of time' is laudable, although it does not address short-term benefits. Consider choosing more specific information that addresses Janet's expressed interest.
Janet: I'd like to know what these magic solutions are you think I haven't tried, but so we're clear,I don't know if I'm ready to commit to anything today, or at all for that matter.
Nurse Clarke: Sure. I'll take you through some quitting techniques we support here at the VA:counselling, medications, behavioral strategies. And while they each help in different ways,we find patients have the most success when they combine the strategies.
Nurse Clarke: Let's discuss how you can prepare to quit smoking.
Janet: I told you - I don't know that I want to quit right now.
Nurse Clarke: This isn't about quitting now. It's about planning how you're going to quit later.
Janet: I'm not ready to plan like that. I'll figure that out on my own.
Coach: Janet isn't ready to discuss a specific plan. Consider ways to explore her needs and preferences--it will save you time and effort!
Nurse Clarke: Counseling seems like it could be right for you.
Janet: Oh yeah? ...why?
Nurse Clarke: Well, you might benefit from having a person who understands what you're going through to talk to about all this.
Janet: I don't think some VA counselor is going to understand what I'm "going through."I stopped drinking without one, and I don't need one now.
Coach: Your suggestion was well-intentioned, though, Janet is not very receptive to being told what would be right for her. Instead, consider gauging her interest in hearing more about counseling.
Nurse Clarke: You mentioned that you struggled with withdrawal symptoms whenever you try to quit.For that we recommend specific medications, things you mentioned trying like gums,lozenges, and patches. How did that work for you?
Janet: The short answer? It didn't. I've been smoking since the Navy, too long for quick-fixes.
Nurse Clarke: What do you mean?
Janet: I'm not some schoolkid smoking clove cigarettes behind the dumpster. I smoke over a pack a day.The gum was good for a quick craving, but it didn't get me close to the finish line.
Coach: Good! You chose to ask an open-ended question and Janet shared her experience with medications for withdrawal symptoms and her understanding of their potential effectiveness for her.
Nurse Clarke: Tell me more about that.
Janet: That's all there is to tell.
Nurse Clarke: You said the gum was good for a quick craving. In what way?
Janet: I just noticed that, compared to the other times I've tried quitting, I didn't... it wasn't as extreme. You know?Like, the spikes when I needed a cigarette. It's not like it kept me smoke-free for good.
Coach: Good choice! Exploring Janet's experience of the week she noted some benefit may help you and her build on previous success.
Nurse Clarke: They might have worked better combined with other quitting methods, but it sounds like they did help a little.
Coach: Though the information was accurate, it felt like advice to Janet, who pushed back a bit. As a result, the accurate reflection about the meds helping had limited impact.
Janet: In the sense that everything helps a little, yes, I suppose so.
Nurse Clarke: Well you don't have to settle on anything now, but it can't hurt to have ideas if you decide to move forward.
Janet: Right. I'll tuck that away in my back pocket if I decide to try quitting again.
Nurse Clarke: How do you want to proceed?
Janet: Honestly, I'm still figuring it out...
Janet: To tell the truth, I wasn't actually planning on coming back after our last visit, but... my grandkids...a few days after my show, I found a pack of cigarettes in their toybox at my house...so I asked them about it, they said they were hiding it from me.I think they look at me like I'm helpless.
Nurse Clarke: But you want to find a way to change that... be their role model.
Janet: Yeah... I do.
Janet: I'm not sure meeting with this smoking expert here at the VA is necessary.But I might try quitting another time on my own.
Nurse Clarke: We can absolutely support you with that decision.
Nurse Clarke: I think we made good progress today.
Janet: "Making progress" wasn't really my agenda today, but sure.
Nurse Clarke: I only mean that you're leaving a lot closer to quitting than when you came in.
Janet: I guess that's true.
Nurse Clarke: You can pick up some resources for quitting at the front desk. We'll touch base again soon. Good luck with everything.
Janet: Thanks.
Coach: At her next visit, Janet reported that she was still smoking and hadn't made any efforts to reduce or quit.