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Well, hello to everybody. I hope that you can hear me and um welcome to this session that we're doing um as part of this overall project with C three and Burdette winning hearts and minds. So just to say my name is Helen Donovan. I'm one of the nurse associates at C three and also an independent nurse consultant. And what I am going to be talking about today is essentially supporting behavior change, but a little bit about C three for those of you who don't know, we are an independent charity with our mission to prevent non communicable diseases. So those diseases that predicate on using tobacco, not eating the right things and not doing enough physical activity. So the aim is obviously to prevent all non communicable diseases. Now, a very key cut part of this is really about supporting behavior change and this is what we are going to do today and talk about. So lifestyle choices, alcohol consumption, diet, smoking, they all we know can seriously affect our health and well being. Um and they cause or contribute to long term conditions um whether that's obesity, heart disease, impact on our mental health quality of life and our well being now, health promotion is a key component of public health and in preventing ill health. And they're all key priorities for us at C three, but also for all UK healthcare and as nurses and as all healthcare practitioners, we have a duty to constantly update our knowledge um and practice. Now, of course, this all sounds easy. Um And if it were, it would be an optimum that nobody smoked, we would all be an ideal weight and we would only drink or only in men moderation. But of course, we know that that's not how it works. Now, why winning hearts and minds? Now, winning hearts and minds is a, is a project that C three are doing in combination with some, some funding from the Burdette Trust. And the aim is to address smoking in mental health units in England. And people with mental health, we know are more likely to be smokers than others. And in fact, and this is actually a conservative estimate, over 40% of people with mental health conditions smoke compared to 14% of the rest of the population. And that obviously puts them at much higher risk of heart disease as well as other diseases and winning hearts and minds is working with mental health to try to sort of address that really. Um I hope that people can see and hear me. All right. Um So changing behavior is not easy as I said before, if we, if it were, we would all do the right thing. So this attention in in tension gap. So everybody has the best intentions. Most people do anyway. We know that these things are the right thing to do. But actually the reality of doing it getting over that line is not that easy. People don't always act in their best interest, they don't always do the right thing. Um And this is part of our sort of challenge with behavior change, health promotion, as I said, is a very key component for us as a public health practitioners and enabling people to increase control over the determinants of health and thereby improve their overall health and well being. Now, it's a comprehensive process. It involves actions directing at strengthening the skills and of the individuals, but also empowering communities and the families around people and changing social and environment conditions in order to make that live. Now, this is a quote from the Who health promotion strategy. Uh and the charter, the Ottawa Charter that came about in 1986. So from a nursing point of view, we've all been there. I know I have, we want people to do things and you have this sort of tennis match conversation with people. Why don't you try? And the person says, well, yes, but I've done this but and you go on like this. So we need to use different um different strap strategies and motivational interviewing is one of them and I'm going to come to that, but we need to sort of use different strategies as well. So I'm just going to do a little touch of the theory behind behavior change before we go on. So we need to think about those wider determinants of health. Um And there's been a lot in the news and in the media quite recently about digital exclusion and more importantly, digital inclusion, the NHS digital inclusion plan is now 10 years old. Um And this was taken from a Guardian article when that digital inclusion strategy was first launched and comparing it to those beverage five giants evils of society which prompted really the introduction of the NHS. Um But adding in this uh the idea of digital exclusion, if people are not able to access a lot of the resources, a lot of the information, and that might not be just because of not having access to the internet as people get older, they may not have the same capacity to be as digital digitally included as perhaps they even once were now one of the sort of classic uh models around behavior change and health promotion relies on this health belief models. So what is it that people really feel is important? Is this a, is this a problem that they really need to address? And I think this is sort of quite key for some of the work that we've been doing around smoking and mental health is, do people really feel that this is a problem? They know the packaging they can see on the side of the packaging that smoking is bad for them. But do they really understand it? So, one of the things is actually some of that education that perceives seriousness and the consequences of the problem. Um and then the benefits of Axion, you know, is this going to affect other bits of my life? Um So how all this leads to people actually wanting to and being able to change their behavior. One of the other models is called the social cognitive theory. So how people learn from individual experiences and the actions of others and how they interact with their community and there are several elements of, of this. Um So self efficacy, efficacy. So the belief that an individual has control and and is able to do things um their behavioral capacity, what they read expectations are what they're expecting, expectancies and any self control also observational learning what they learn from others around them. And this is particularly important in sort of communities and family engagement and then reinforcement are there people around to support that behavior change? So all of this goes into what has become the social cognitive theory. And then the last one which I think also almost encompasses all of them, which is the combined model or com stands for capability, motivation and opportunity. Um And all of those elements are required in order to change people's behavior and all of these predicated around people's ability to change. And it's a really complex process and the changes of the, the change, the stages of change model, which sort of comes from the protest, SCCA and Dick lament Iwork from the seventies, which was mostly around smoking cessation but has been used in all sorts of behavior change. Um But really works on the fact that people will go forwards and backwards. It's a spiral almost. So they may be thinking about changing, they may then think, well, okay, I'm ready to change. What am I going to do and then the preparation and then actually doing the change and then of course, this is some of the most challenging is maintaining it. But also recognizing that a lot of people will relapse. So with smoking, they may then go and have a cigarette and how you then sort of to get over that hurdle and go back to not smoking again. And when we think about public health and health promotion, we need to think it in that wider context that it's really important that we work in an upstream approach, we can't constantly be managing the causes of some of these. So this concept of solu to genesis, which is the opposite of pathogenesis, how people feel and well their quality of life and their well being all promotes this upstream approach. So consultations to support behavior change and using motivational interviewing. And this is what I'm going to spend that the next few minutes talking about getting people to do the right thing is one thing but right for who. So what we really need to start off with is asking what matters to you and how ready people are to change. Um So, um you know, asking people to vocalize how ready they are and one of the tools that you can use is using a scale on a scale of 1 to 10. So if I asked you on a scale of 1 to 10, how ready are you to stop smoking? And if they from one to not a tool or 10? Yeah, I need to do this. I'm ready to do it. And that sort of helps you assess the people, people's level of motivation and whether you'll say okay, well, we'll come back to this at another time or okay. What can I do? Can I give you some support about maybe vaping or nicotine replacement? So these are just some of the resources that there are out there around behavior change. This is um the UK HSA all our health toolkit, which has some wonderful resources. But this is particularly looking at smoking and tobacco use. The National Center for Smoking cessation training has some resources. This is a resource that the Royal College of Nursing have on behavior change. And this is the BMJ motivational interviewing toolkit. So the principles of motivation, national interviewing is first of all engaging and this goes back to that earlier slide, you know, how ready are people? Are you ready to work together and what is important? So that's the next bit focusing what it is it to change and why is that? So evoking that sense, whether that's to save money, whether it's for their health, for most people, it's going to be a combination of things and then planning how to do that is really important. I can't see any messages at all. So I'm really hoping that this is coming through principles of motivational interviewing or the rule of test. So the R stands for resist the urge to change the individuals course of actions through didactic means, the U stands for understand it's the individuals reasons for change and not those that the practitioner is wanting to isn't. So, you know, again, going back to that readiness and why people want to make this change. The L is really important as part of listening, those communication strategies. What is it again, that is going to make a difference to this particular person and then empowering people to have the ability to change. So some useful hints to um sort of try and assess people's readiness for change. So first of all, if you're talking about smoking, rather than considering they change as such, maybe ask what's the impact that smoking is having on your life? Um So the healthcare professional may well say something like, you know, on a scale of 1 to 10 from smoking, being not impacting my life to smoking is really impacting what best reflects how you feel. You know, and that then allows people to think. Well, actually it's really costing me a lot of money. I'm not able to afford my rent. And obviously the cigarettes are really impacting on that. And if somebody says they're five, and the healthcare professional, like, say, well, okay, well, where were you say six months ago? And they might say, well, actually I was, I was worse than that. I was three. So it sounds as if you're getting, it's getting worse for you. What's made you go from a three to a six and six months ago to a five? Now, please, excuse me. And, and it might be the cost. I'm just putting examples. My family are nagging me. It's worrying me and I know that if I wasn't buying tobacco, it would help. So this gives you your opening. Really? So what would it take you to go from a six or five now to maybe an eight on the scale? Um, and this is where somebody might think. Well, I need some help with some nicotine replacement help here. So what are the questions that you might need to think about to illicit or voke that change? So what matters to you? So what would be a really good thing to think about, if you were to stop smoke, smoking, what would your life be like three years from now if you stop smoking? Um, and what do you think others are concerned about, about your smoking? So, those are the sort of things that you might want to think about using as part of your conversations. And then of course, it's, well, how can I help? We know that it's difficult doing these things. How can I help? How can I help get past some of those difficulties? Um If you decide to stop smoking, what do you think you would need to do to make this happen? And then what change is going to be positive? Again, getting people to think about the positive. So um ask if you think, well, the extreme consequence of this not happening. So running out of money. So I suppose you don't change, what's the worst that's going to happen? And then also what's the best thing that you could imagine happening it? Or if you make the changes, how would your life be different from it is today? Um And again, going back to that sort of future planning, what would you like things to turn out for you? So asking open ended questions, giving people the opportunity to sort of tell you. So tell me what's happened since we last met or since I last saw you, what makes you think it might be time for you to change? And these might not be used in isolations. Of course, they're entwined throughout the conversation because you need to also listen, I hear you saying this, I hear you talking about the money. Is that something that's really bothering you? It's obviously really challenging at the moment. I get a sense that you're waiting to change, but you've got concerns about how it's going to affect, you know, your ability, your mood, maybe. Um And then obviously affirming and clarifying can see this is upsetting. You're doing really well to stay with it. What have you, what, what can I do to support you some of the techniques, then again, sort of moving on to summarizing. So it sounds as if you're concerned about your smoking because it's costing you a lot of money. You also said that quitting is going to mean so not, you know, not being able to go with your friends anymore. That doesn't sound like an easy choice. And that, that's often one of the things that we here for people in, in, in, particularly in mental health institutions in as in patient's that ability to be part of that sort of crowd if you like. So that's a difficult challenge for people. Um So elicit those self motivational statements, it seems you've been working hard to quit smoking, is that different from before and what's changed? So this is a case study um that I, I worked with some colleagues to, to pull out. So if we, we've made up the name Errol is 19. He began smoking as an inpatient during his first admission, during a severe psychotic breakdown, he recalls being bored, lonely and smoking filled the time. So he continued to smoke at least 20 cigarettes a day for the next five years. His daily activity mainly in watch, watching television, going to the local shop to get cigarettes mainly and smoking, domestic chores were undertaken by his mother. So he didn't have that to think about rarely initiated conversation, monosyllabic responses and non existent social life. Nobody else in the family smoked and he smoked all over the house. Really annoying. His family left cigarettes ends everywhere which caused seek frequent arguments and concerns about fire. Um was often re admitted to hospital post, all these arguments. And during his last admission, he expressed frustration that this was his life going nowhere. Um And what he wanted to do things differently. So key interventions with this family for me, Errol was surrounded by criticism. He had really low self esteem anyway, and his family were increasingly frustrated by him. Um Could these be tapped into again? What would help would he be required in terms of the psychoeducation share ing and understanding of what smoking does and what people and why people with severe mental ill health smoke. So come to the care plan on the next slide, but really important to include his family support network. Really important to help that reinforcing of the good things and give him that self esteem. Uh and roll rehearsal. What happens when somebody offers you a cigarette? So talking about those activities is going to the shop to buy cigarettes and what's going to trigger that. So really important to go through all those things. So this is just showing the care plans. There's a lot on this slide, I'm going to go to through it very briefly, you will have access to these. Um So his concern was um that he was very unhealthy and overweight and this was obviously his care plan really important to strengthen that. It's his care plan, not the healthcare professionals. So his goal was to get healthier and to stop smoking. So what was done was to construct an activity schedule with peer support worker, attend weekly meetings on smoking, cessation, smoking cessation team offered brief counseling, prescribed nicotine patches in this case and continued follow up with support to prevent a relapse and the other Axion that was to join a gym. So Errol also said I'm minimal conversations with people and I don't want to be so lonely. So for his goal was for the care team to offer consistent supportive approach and engage in those conversations, regain his libido, he wanted to have a girlfriend. Um So practice conversations with a peer supporter. Again, you know, getting into that sort of role would play um 15 minutes three times a week. He also aimed to spend time with his sister, attend recovery college with communication classes, um and set up some social media to link again with friends and peers. So in summary, for Errol, motivational interviewing, patient centered consultations were really useful in guiding the conversations about change. But also it relies on people's using their own motivation, you can't do it for people. Um And that needs to be done with, as I said again, with that care care plan with Errol, that was his care plan. There's a body of emerging evidence to show that it can motivational interviewing these sorts of techniques really can help in clinical situations. People have often heard the logical arguments in favor of change, but you need to often go back to, well, what's really matters to you. People will be ambivalent about changing because it's hard and also they probably like having a cigarette and they like the fact that it sort of gives them that's something to do. Um You can and should offer expert advice where appropriate. But at the same part time, emphasizing this is up to them, aimed for the arguments in favor of change to come from them rather than you giving them. And also uh remember that that relapse part of the change cycle. So people will relapse and that's an expected part. So support people through that. Now, I've nearly at the end of this, I cannot see any questions in the chat. So I am hoping that, that this has come through. Um Finally just a little plea to get involved with C three. We have got time for questions. Um Just leave it up for a little bit longer. Okay. I can't see, I can't see any, got a message. Thank you, Louise. Um Louise is asking, she says that's really helpful. Is there a common stage in the cycle that people find the most difficult? And I'm not sure that there's any evidence of this. But in my experience, I think the biggest hurdle. Well, I think there's two hurdles i the maintaining. But I think the first one is to get to that from that sort of pre contemplation, contemplation to actually planning and making the change. Um So I'm not sure that those would, would, would bear out in the, in the evidence. But from my experience, I don't know whether you would agree with that, but I think that it's getting there and then maintaining it and of course, the main, the getting their happens again when people relapse and people do relapse, we know that. Um So, well, it's really good to have that question because at least I know that I haven't been talking to myself, but I think that was, that's it. So, thank you very much for listening and I'm really glad it was useful. Um And hope obviously this will be available on the medal platform and through the C three pages on winning hearts and minds, so you'll be able to access this. Thank you very much. I'm going to end the session now.