Establish Rapport

The discussion should begin with open questions to get patients talking, and is an ideal opportunity to find out what it is they want to know and what they expect from the health care professional. Questions should begin with words like how, what and could you/can you. For example, 'How did you feel when you were told that you had diabetes'?', 'What concerns you most about your

Assess importance and confidence (and readiness)

Figure 3.1 Key stages in the consultation Reproduced from Rollnick etal. (21), p.12.

diabetes?'. Avoid phrases including words such as 'difficulties', 'problems' and 'help' as this implies that you perceive them as having problems when this may not be the way that they see things themselves. Closed questions require a yes or no response; they can be used once discussion has been initiated and are a useful way of checking your understanding of the conversation. 'Did you say that you have tried that diet five times before?' Another useful opener to establish rapport would be to use a typical day (21). For example, 'Can you take me through a typical day in your life, so that I can understand in more detail what happens?' or 'Can you think of a recent typical day? Take me through this from beginning to end'.

Active listening is an essential skill for this process of communication and counselling to work effectively. It is hard work, as it includes attending to your own non-verbal and verbal behaviour as well as that of your patient. It uses minimal encouragements such as mmm's, aah's, nods and varying degrees of eye contact to encourage people to continue and to let them know that you are listening. Silence can be one of the most useful tools in this arsenal, but for many it proves to be difficult, as the urge to speak and fill the silence is so great. This is a greatly missed opportunity, as it allows patients time to collect their thoughts for a response rather than having them hijacked with your ideas or solutions. This can be very premature as you may not fully understand the real dilemma for the patient. Silence has long been noted to be a difficult tool for health providers, Rollnick et al. (21) suggest saying a rhyme to yourself to allow that passage of time before the patient speaks. Silence enables a period of reflection on what has passed and a guide to the direction of the conversation so far, and therefore helps you and the patient move forward.

Once a rapport has been established reflect back comments both to show that you are listening and to check that you have correctly understood what the patient is trying to say. A simple reflection could be 'You've tried many diets then.

Paraphrasing is another method to use, and is a way of summing up the essence of the conversation and providing more concrete information than simple reflection. It conveys to patients that you are with them, crystallises comments, checks accuracy and gives direction. It is aimed more at content rather than feeling. 'It sounds as if you have tried lots of diets in the past, one of which you found particularly good for you as it resulted in the 2 stone weight loss that you were after.' Paraphrasing should always be applied tentatively to show that you are checking your understanding of the conversation so far. It is a way of clarifying the conversation for both of you, and can be a useful way of highlighting good and positive aspects of a patient's situation which can often be overlooked (22). For example, 'It sounds like you were really pleased with the way that you dealt with that hypo.'

Being able to keep the conversation to the point is an essential skill when using this approach, and clarifying questions and paraphrasing concisely can help.'It sounds as if you have a number of concerns about your eating and weight. Which would you like to talk about, or shall we talk about these one by one?'' Vague solutions to vague problems will never be effective, so clarify statements; ' You say that ''it'', that is the diet, always makes you feel bad'. By drawing out these emotions and feelings it is possible to clarify exactly what the patient is trying to say. It is important to identify their concerns about diet, health, weight and diabetes as these will influence both their behaviour and outcomes, and determine the agenda for the discussion.

Reflecting feelings is important and needs to be dealt with as they arise. Recognising signs, verbal and non-verbal, will help with this. Watch out for giggling, tearfulness, fidgeting, wringing of hands, crying, etc. Feelings must be acknowledged and labelled; 'you seem to be angry with the way events have gone', ...'I sense you're frustrated with your diabetes',... 'it sounds like you felt let down',... Acknowledging feelings as they arise is another way of indicating that you have heard what the patient said, and are able to empathise with the feelings that a certain situation or event has caused. It shows understanding and demonstrates active listening is taking place.

Open discussion provides valuable insight into the attitudes, beliefs and lifestyle that have influenced patients' eating behaviour. They may have encountered different messages, approaches and attitudes towards diabetes, weight and eating in the past. These will have influenced their behaviour and need exploring (23). While information-giving can improve confidence and reduce anxiety, be clear why information is being given, find out what the patient already knows, ask patients' views before giving your own (20). Patients need to be given the opportunity to talk and the environment should be conducive towards this. Acknowledge the patient's expectations and allay their anxieties. The key to any good discussion is an understanding of the patient's current situation. How are they coping with the diagnosis, are they ready to make changes, and what is the level of personal responsibility for the management of their diabetes (24)? These factors will determine the type of responses that are required, as well as the type of strategies that may be used (24,25).

In summary, to start the consultation:

• Use open questions

— to establish rapport

— to identify patients' concerns

— to examine patients' beliefs, attitudes, values and understanding of diabetes, weight, eating and exercise

—A typical day can help to open discussion

• Use closed questions to clarify points.

• Use silence to allow thoughts to be gathered.

• Reflect content to check understanding.

• Acknowledge and reflect emotions as they arise.

• Paraphrase and clarify points as they arise.

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