There are potentially four different ways in which change counselling methods might be used in typical diabetes services: (a) the health care professional could employ the method within a routine clinic or home visit, spending time clarifying an individual's stage of change and employing a stage-specific strategy; (b) during a formal annual review, where self-management issues could be put on the agenda and explored more routinely; (c) change counselling methods could be used more extensively for targeted (high-risk or high-need) patients, with special clinics and more consultation time. These clinics could provide patients with continuity, allow the health professional to assume a key worker role and facilitate the development of a consistent relationship; (d) these principles could be used by a service to define the ethos (counselling/motivational), protocols (open-ended questions, reflections, patient summaries, screening for emotional/behavioural barriers), intermediate outcome measures (stage of change, self-efficacy and quality of life), and the content of locally produced information leaflets.

In reality, it is hard for staff to change their existing routines, and evidence suggests that it is hard to maintain new ways of working23,118. A service wishing to adopt the methods outlined in this chapter will need to manage change in a similar fashion to their patients? Do the members of the service own the changes, have they been allowed to voice their fears or resistance, have they reviewed the pros and cons, have they thought through the details of introducing the change and agreed SMARTs plans, is there praise and support for the changes, and are the cues or reminders in place to create new routines? Specially trained staff with dedicated sessions to pursue this may be more effective. However, there is a strong suggestion from a development project that change counselling skills cannot be separated from diabetes skills, as the patients' agenda demands that both are needed within one consultation23. Training in change counselling skills is necessary, as nurse training does not routinely address change counselling competencies.

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