Power and safety in health conversations
Osca have been delivering Coaching for Health training to health and social care professionals for the last decade. The programme focuses on the conversational skills necessary to support patients and clients with behaviour change and self-management, and to take as much ownership for their health as possible. It’s not easy, for the professional and the client. The following essay by Nick Nielsen and Dr Doug Hing was commissioned by Nesta and explores the dynamics on both sides, plus how to maximise the likelihood of effective conversations.
Mr Z has been called in to review his diabetes. You see that he is overweight and smells of cigarette smoke. He’s missed most of his specialist appointments and his blood results show things are getting worse despite recently starting another medication. His past records show that he has been told many times to eat healthily and to exercise more. He has a young family and his job often involves working late shifts which he has always said made it impossible for him to exercise regularly or eat healthily.
Does this scenario seem familiar? In the opinion of many health professionals, significant numbers of the patients and clients they see don’t take enough responsibility for their health in spite of all the risks. There may be things in the way, but many of these often lie outside the health professional’s immediate sphere of influence, such as personal choices and social issues.
What is the likely reaction for the health professional? It could be frustration, it could be annoyance, but the heart of it is likely to be the feeling of powerlessness – the health professional’s powerlessness to say or do anything that would, in their view, improve the client’s health.
The sense of powerlessness is often difficult to recognise, it is not one we welcome in our lives. We don’t want to be reminded of life’s fundamental unpredictability, nor the lack of control we have in so many areas of our lives on a day-to-day basis. In fact, we as human beings do a great deal to avoid it.
And health professionals are under a great deal of pressure, particularly as there is a powerful cultural expectation – held by many of us – that the role of the health professional is to ‘fix’ things. Health professionals work in this profession because they care and want to be able to help, to make a difference.
Hence, what might be a health professional’s reaction to their own sense of powerlessness in a situation with a client? Where they feel the client isn’t taking sufficient responsibility, it’s natural for the health professional to want to step in and try to rescue the situation by taking control, to try and fix things.
Interestingly, a similar dynamic may be happening for the patient or client.
Having a chronic condition is often life changing and can cause significant feelings of powerlessness. The client may feel they don’t understand the process – what happened, what it means, what will happen in the future and the likely risks. It’s easy for them to imagine the worst, even at a subconscious level, which can prompt a great deal of fear. So great in fact that they may feel unable to face the situation. Hence, a natural reaction is to try and shut out the situation and remain in the safer present day, even though this may pose profound risks to their long-term health.
This can manifest in different ways. For example, an individual that simply smiles and nods as a health professional explains the risks but finds it difficult to accept their situation, to take the information in. Or normalisation: “well, everyone in my family has diabetes, it’s not a big deal”. Or simply giving the issue a lower priority: “I don’t have time to address this as my work / finances / home life is more important at the moment”.
The feeling of powerlessness by both clients and health professionals can create a polarised dynamic that plays out in conversations up and down the country, every minute of every working day.
A client feeling powerless is likely to withdraw and avoid engaging with both their situation and the conversation, which can mean health professionals feel powerless in turn, prompting them to try and step in and take control. The more control health professionals try to take, the more pressure clients can feel, increasing their (often subconscious) experience of fear, and the associated withdrawal and resistance.
Unfortunately, the results of these types of conversations are often unproductive.
Because from one perspective, when it comes to managing long-term conditions, health professionals can be considered to actually have very limited power. If a conversation lasts ten minutes, that leaves 6,710 minutes the client has on their own in a waking week to make changes (assuming they sleep eight hours a day and also assuming there is contact weekly which is often not the case). The key decisions and actions that actually affect the client’s health outcomes – what they eat and drink, whether they exercise, if they smoke, or how often they take their medications – happen in the 6,710 minutes of that week, not the ten minutes. I.e. they happen in the client’s own time.
So, while shared decision making and other ideas of the health professional ‘empowering’ the client has been around for years – a key question is: how much power and control did the health professional have in the first place? Our answer is not a great deal.
While this may be a challenging realisation due to the discomfort that come from the sense of powerlessness, it can ultimately be very freeing.
Because, if health professionals are able to accept the limitations of control they actually have, it frees them up to have a different kind of conversation; to relinquish the expectation that it is up to the health professionals to fix things, that they have the power. It means that, whilst health professionals don’t relinquish their care for the client, they can take a step back.
And by taking a step back, space can be made for the client to come forwards.
Counterintuitively, while we might expect that stepping back diminishes the sense of urgency in the situation, and hence the likelihood of change, it actually tends to have the opposite effect. By stepping back and doing more asking than telling, we can achieve more engagement, increase satisfaction and improve health outcomes.
However, this is easily said, and not quite so easily done.
It all starts with ourselves. First, it is important to recognise and accept the powerlessness in the dynamic of the health professional with the client. No matter how much a health professional cares, how many good ideas they have or how knowledgeable they are about the risks, ultimately the client will only change if they want to, and when it comes to lifestyle behaviour change, most of the time people already know a lot about what they ‘should’ be doing.
Coming to terms with powerlessness happens at both a theoretical and an emotional level.
At a theoretical level, the limitations of power can be considered as a consequence of: the lack of time available in the conversation between health professionals and clients (particularly when compared to the time the client has with themselves); the limited impact of all the advice and ‘telling’ over the years (‘eat less’, ‘exercise more’, ‘stop smoking/drinking/taking drugs’, ‘take your pills’ …); the many other influences on the client (including other health information and mis-information across different media); and our understanding of how easy it is for us all to avoid changing especially if there is underlying fear.
At an emotional level, we can feel the sense of powerlessness when we become frustrated, angry and/or confused by a lack of change. This can be particularly pronounced when there is an expectation of a solution or ‘fix’ and the associated sense of ‘failure’, potentially by both the health professional and client, when the behaviour has not changed.
Being aware of the expectations that often exist helps to highlight the fundamental component in supporting clients to move towards accepting and opening up to address their situation:
To varying degrees, as it is the sense of fear and powerlessness which makes all of us avoid our issues, then it is only a sense of safety which will help us confront them. Even in limited time, it is incredible the sense of safety and space that skilled professionals can create.
Crucially, for health practitioners to relax their expectations of themselves and relinquish their sense of control, they need to provide for themselves what they try to give to their clients: the sense of space and safety. The space and safety from their own unrealistic expectations of themselves.
So how is space and safety created?
First, it’s about the health professionals
As explored above, it starts with the theoretical – the recognition of the limited control health professionals have over their clients’ lives. This is made harder by the expectation to be the ‘fixers’ and providers of solutions by both clients and health professionals themselves.
So, for health professionals, it is about learning to be comfortable, emotionally, with their limitations of power whilst recognising all the factors that make this difficult; that might prompt professionals to try and step in and fix things for the client instead of making space. Besides expectations, other factors can also include pressures due to a lack of time, targets, hunger, fatigue, mood and even stressors from colleagues or home etc.
Recognising these factors is often the first step. If the challenges, along with the limits of influence can be identified, we all can begin to feel more comfortable with our limits. Because, in situations like the client scenario described, there is no ‘right answer’, there may be no immediate results. The client is the expert in their own life and only they can make the changes that may be required.
Doing this consistently, whether in the moment or afterwards, can help develop a level of comfort, making it easier to breathe in the moment, and to settle the need to control and fix. Because no matter how much health professionals know or much they try, only the client has control over the other 6,710 minutes of their week.
So instead of getting things ‘right’, the aim has to be to create as much of a safe ‘transformational space’ for conversations as possible, while remaining open to seeing what happens. This often means recognising that it is a journey, and ‘results’ may not happen in just one conversation.
Then, it’s about the client
Next, it’s about understanding and empathising with where the client is, perhaps with regards to a perceived lack of control and any fear and discomfort they may feel in their circumstances. This empathy helps to build the sense of safety as quickly as possible – to maximise the transformational impact of the conversation. Without safety, a client cannot be honest with the health professional or even with themselves about the risks they face and what they may need to do about it.
The lack of improvements in behaviour change shows when this isn’t working and can often be as a result of a lack of honesty in the conversation. This can manifest as clients telling professionals what they think professionals want to hear, or simply nodding and smiling but making no actual changes afterwards. Occasionally the resistance can be more explicit, with clients denying there is an issue at all and/or refusing to engage in the conversation.
Ultimately, it’s about health professionals and clients
Health professionals are experts in their field, usually generalised to a population and established with training and experience. Clients are experts in themselves, their situation and also their values and preferences regarding any advice a professional will provide. Consequently, it is crucial for health professionals and clients to come together and explore these values which will ultimately determine whether any advice from the professional is followed or whether clients will make any changes. In these difficult situations, the limitations of the health professional’s power is managed by utilising the client’s power; the power from the health professional’s ten minutes utilising the client’s full potential in their 6,710 minutes and beyond.
Building safety by establishing trust and rapport
At Osca, we have been delivering a programme called Coaching for Health since 2012. We have trained over two thousand health professionals around the country in various roles across health and social care. In partnership with our participants and trainers, we have strived to hone our curriculum down to the essentials required for creating transformational conversations. Safety through trust and rapport, while simple and not new, continues to arise as one of the core components of an effective approach. The following are a few insights from what we have learned to be helpful:
An enabling mindset
In our courses, we discuss five core principles which form the fundamentals of the approach. These describe the philosophy or mindset or attitudes we recommend health professionals embody in conversations with their clients. They are:
- Where the client is now is ‘OK’
- If it’s desired, it’s possible
- The client has the resources to start now
- Coaching addresses the whole person
- Their plans are the best plans
Importantly, these principles are not truths and do not guarantee any particular behaviour change outcome, because the client is ultimately in control of what they eventually do and don’t do. However, they can be considerably helpful as an approach to conversations and particularly in situations where there is a sense of powerlessness.
Below is a brief exploration of our first core principle which is fundamental for building safety by establishing trust and rapport.
Principle 1 – ‘Where the client is now, is OK.’
This means, irrespective of where the client is at the start of the conversation, the health professional sees them as ‘OK’, even if they are not ‘OK’ in the professional’s opinion and/or in the client’s. This does not mean accepting and not challenging an inappropriate situation or not wanting or hoping for improvement or change, instead this principle is about seeing behaviour change as a journey and it is ‘OK’ for the client, wherever they are, to be at the beginning of this journey. Ultimately, at the heart of this principle is the pursuit of a non-judgemental approach.
Why not simply say ‘non-judgemental’? Because we believe we need to go further. The challenge is that we all judge, all of the time. We can’t avoid it and the triggers described above often exacerbate our judgements. The challenge is for health professionals to be aware of them as the first step, and then to manage them as well as they can.
The principle recognises also how much our clients may feel judged already, if for example they are continuing to smoke, drink, take drugs, avoid exercise, eat unhealthily, not take their medication or not follow all the advice given to them by other health professionals. Many clients will feel judged by the very institution health professionals represent, before they meet or even talk to the professional.
So, we often need to go further than just being non-judgemental. We call it ‘radical acceptance’ of wherever the client is – whether they currently want to change or not. If health professionals can subtly communicate to the client that they are safe where they are, in that moment; that they are not going to be judged irrespective of what they are or aren’t doing, then there is a greater chance of honesty and potential change.
In the limited time available for such conversations, it’s hard to find a window to do anything additional. However, if time is invested to build safety in the relationship at the outset, there is likely to be more honesty and engagement, which can help save time in the long run – even if it’s over multiple conversations. Creating safety is foundational to a person-centred approach. Not only is it good in its own right as it shows respect, it is also a pragmatic approach as the resulting conversations are likely to become more efficient and effective.
In addition, not only does the evidence attest to benefits for patients and clients in terms of satisfaction and health outcomes, the health professionals we’ve trained and worked with over many years regularly communicate to us how much better they feel about their work. Because they have been able to relinquish the often unrealistic expectations they hold of themselves to fix situations they can’t, there is an emotional liberation and practitioners report enjoying their jobs more. In environments of increasing pressures and significant issues with workforce retention, this is becoming increasingly important.
This is the fifth similar conversation with Mr. Z, and sitting there, the health professional recognises their frustration and the resulting desire to take control but also to give up responsibility by dismissing the patient as impossible to help. After a brief pause to gather their thoughts, the health professional tries a different approach and starts asking Mr. Z about what he wants to talk about and what is happening in his wider life. It takes some sensitive questioning, but Mr. Z eventually talks about his worries about finances, bullying at work, difficulties sleeping and the struggles his children have with behaviour. The health professional reflects back what they heard and with curiosity, asks what is most important to Mr. Z and what ideas he has. Through exploring this, Mr. Z says that he will make time to discuss matters with his wife and also address issues at work. In the final few minutes, the health professional asks permission to discuss the blood results, and asks how Mr. Z is getting on with the medication. With the established safety, and the new levels of trust, Mr. Z is honest about the fact that he’s not taking the medication regularly but also that he knows he should as his condition is not improving. He decides to start taking the medication regularly and also to include talking about diet and smoking with his wife who is supportive of making changes. The consultation ends with both parties feeling better and trust established for more fruitful future conversations.
 Kivele, K., Elo, S., Kynges, H. and Keerieinen, M., (2014). The effects of health coaching on adult patients with chronic diseases: A systematic review. Patient Education and Counseling, 97(2), p.147