Guiding and directive approaches
Communication techniques to try out
Below are some ideas for how practitioners can use a guiding approach (and support parents/carers' autonomy, competence and relatedness). Most importantly, this approach is about getting to know the parent/carer and family (i.e. their lifestyle, preferences, constraints), coming from their perspective (i.e. what does it feel like to be them?) and helping them set appropriate goals that fit within their lifestyle (i.e. tailoring support to the individual).
After reading each technique, ask yourself how much you currently use this and how you might implement it into your practice.
For some practitioners these techniques will come naturally, or you may be practicing in this way already. If this is you, the following section may simply affirm what you are doing and provide you with confidence in your approach.
For other practitioners, these techniques may be new and may appear a daunting task. If this is you, be reassured by the fact that many people feel this way. People think communication should be easy but in fact can be very challenging. Rather than trying to implement these techniques all at once, perhaps pick one or two to try out first. Then once you are comfortable with them, come back to the module and move onto some more techniques.
Talk the parent/carer through the consultation
It can help put a parent/carer at ease by talking them through what to expect from the consultation. For example, how long it will last, what you will talk about, and what they can expect from the time you are together. It is useful once you’ve explained this to ask “how does that sound?”, which gives them an opportunity to raise any concerns or add anything they would like to say.
Ask open-ended questions to find out about the parent/carer's needs
Open-ended questions are questions that encourage parents/carers to talk and cannot be answered with a one word or short response (questions that lead to a limited response, such as ‘yes/no/a little bit’ are called “closed questions”). Open-ended questions often start with words such as ‘how’ or ‘why’ or might use phrases such as ‘tell me about’. Open-ended questions can be used to explore families’ current lifestyles (e.g. ‘tell me about your child’s current physical activity’), motivations (e.g. ‘what are your reasons for coming here today?’) and to help them come up with ideas for change (e.g. ‘how might you be able to help your child be more active?’). In turn this will help parents/carers feel more autonomous and will move practitioners away from telling an individual what to do. People are more likely to make changes when they hear themselves making the arguments for change, and feel that the change is their choice.
Reflect back what the parent/carer has told you to acknowledge their needs and demonstrate you are listening (reflective listening)
Reflective listening involves paraphrasing what an individual has said and repeating it back in your own words (e.g. Parent/carer: ‘I’m really struggling with this right now’; Practitioner: ‘you’re finding things a bit challenging’). This conveys that you have heard what they said and makes sure that you heard what you think you heard. This can be particularly useful if someone is upset or angry.
Offer the parent/carer opportunity to have a choice in any areas of change (e.g. physical activity and diet)
A key component of developing autonomy is parents/carers feeling they have a choice in what they’re doing. This can be done by asking them if they are happy to discuss their child’s weight, or their lifestyle. Then going on to ask them to come up with ideas for changing their child’s diet or physical activity. If they are looking for guidance from you (which parents/carers often are), you could offer ‘guided choice’, which involves providing parents/carers with some appropriate options and asking them to choose amongst those options (see module on behaviour change techniques for further information on 'guided goalsetting' with parents/carers).
Ask permission to give advice or ask personal questions
Despite your good intentions to help, parents/carers may perceive advice negatively (or switch off) if it is delivered in a directive manner. Before jumping in with advice it can be helpful to ask permission from the parent/carer (e.g. ‘is it okay if we go through X?’ or ‘could I make some suggestions?’). This feels less like you are telling the parent/carer what to do and gives them some control (autonomy) over the situation.
Provide meaningful rationale for suggestions (e.g. physical activity and diet)
People feel much more motivated to do something if they understand why it is important (rather than just being told to do it). When making suggestions to parents/carers (e.g. about physical activity or diet), try and explain your rationale and how these suggestions will benefit their child and their family (the more personally relevant the better).
Offer meaningful and specific praise/feedback:
Making short positive statements (e.g. ‘you’ve come up with some really good ideas here’) can help individuals acknowledge their positive behaviours and strengths and help them develop confidence in their ability to change (thus enhancing feelings of competence). This can convey respect and understanding towards the person you are working with.
Use summarising statements:
Summarising statements involve providing an overview summary of what you have discussed so far (e.g. the family’s lifestyle, preferences, any goals set). Summaries can be useful if you “get stuck” at any point in the conversation, or at the end of the interaction to remind parents/carers what you have talked about and what the next steps are. This demonstrates you have heard what they have to say, and gives the parent/carer chance to correct anything you may have misinterpreted.
Give the parent/carer space to ask questions or request clarification:
It is important parents/carers understand all aspects of the conversation and feel comfortable enough to tell you if they don’t. You can raise this at the start of the consultation (e.g. “if at any time you don’t understand something please ask”), during (e.g. “does that make sense / do you have any questions?”) and after the consultation (e.g. “are there any further questions you’d like to ask about what we’ve discussed?”).
Communication techniques to avoid
It is important to minimise the use of the following communication techniques. These directive strategies can be perceived as controlling by parents/carers, and reduce parents/carers’ sense of autonomy, competence and relatedness:
Use jargon, or technical terms that the parent/carer might not understand
It is important not to use jargon or technical terms that the parent/carer may not understand. This can include terms that are commonly used in healthcare settings (e.g., BMI) but may be unfamiliar to non-experts. If a parent/carer doesn’t understand your language they may feel embarrassed or ashamed to ask for clarification, and may gain little from the conversation.
Tell the parent/carer they 'must' (not) or 'should' (not) do something
Telling parents/carers they must or should do something reduces their feeling of autonomy and subsequently their likelihood of making changes. The things you might think the parent/carer needs to change may not be their priority or may not be feasible within their current means or lifestyle.
Use forceful 'if, then' language
If a practitioner uses forceful “if, then” language during a consultation this may appear to parents/carers that they will only see gains if they do things in a certain way, or unless they “do something”, they will see a negative consequence, e.g., ‘you’re going to have to work if you want to see improvements’, ‘if you don’t do something about this your child’s weight will continue to increase’.
Activities to help develop a guiding approach
Activity 1 - identifying communication strategies
In the videos below the practitioner is using two different approaches to discuss a child's weight with their parent. The first video uses a guiding approach and the second video uses a directive approach.
As you’re watching each video, use the checklist provided and mark what techniques the practitioner is using with the parent. What effect did this have for the parent? How did you feel watching this? Note any thoughts you have in the space provided in the checklist.
A guiding approach
A directive approach
Interested in what’s going on in these consultations? In the videos below Daisy discusses how the components of each consultation either support or diminish the parent’s autonomy, competence and relatedness.
Activity 2 - Reflecting on your own practice
Now you have watched the different communication styles, use the checklist to reflect on your own practice. What do you do already? What could you do more of?
Activity 3 - Practicing techniques
Activity 4 - Practicing in “live” settings with parents/carers
The best way to develop a skill is to practice. Communication is no different. Now you’ve observed a practitioner in a guiding consultation and reflected on what you could change about your own practice, the next step is to try it out.
You could practice organically when you see a parent/carer within a routine contact. Or if this is challenging to do (e.g., if you don’t have many contacts or feel these appointments are too short), consider if you could invite a parent/carer specifically to take part in a “practice consultation” with you.
Explain to the parent/carer you have been doing some training and would like the opportunity to further develop your skills, through giving them some support with their child’s physical activity and nutrition. You could explain to them in advance what you might like to talk about and what types of questions you might ask, so they can have a think beforehand about what they feel is going well and anything they’d like to ask you about.
And don’t worry about it (not) being perfect – showing you are human and are continuously learning will help build rapport, which is an important element for enhancing motivation (i.e., through relatedness).
If you don’t yet feel you have the knowledge to have a “live” conversation about physical activity and diet, the infant and child nutrition and physical activity and sedentary behaviour modules provide guidance to help with this.
Raising the issue of weight
The opportunities you have to raise child weight issues will depend on your professional role and types of contact with pre-school children and their parents. The communication strategies in this module can be incorporated within any “guiding” conversation with a parent, whether it takes place informally in a children’s centre, the family's home or in a healthcare setting. One of the most challenging things can be making that first step and knowing what to say to raise the child’s weight or lifestyle issue. Some specific examples are provided in the roles and responsibilities module to guide different professionals on bringing up weight in different situations.
Dealing with resistance
Unfortunately not all parents/carers will be as compliant as the video examples in this module. Some parents/carers may be resistant, defensive, or present repeated barriers as to why they are unable to change.
If someone is resistant to change it is important not to jump in and try and tell them what to do. This can be difficult because often you can see how changing will be beneficial for the parent/carer and their child. However, presenting only one side of the argument (i.e., that they need to change and why) may lead to further defensiveness or may make parents/carers reluctant to return for further consultations.
Instead try using the guiding techniques outlined above to structure the conversation in a way that encourages the parent/carer to voice the possibilities of changing themselves (e.g. through open-ended questions, reflective listening and asking permission). When people hear themselves making these arguments, they are more likely to believe they can change, and more likely to turn their intentions into action.
Patience, empathy and reflective listening are very important when working with parents/carers who are resistant. Try coming from the parent’s/carer’s perspective, listening to their concerns and reflecting back to show you understand, and they will begin to feel that you care, and may slowly open up to the possibility of change.
Remember this may take time, so focus on small steps and be careful not to exert any pressure. For example, you may start in the first session with just getting to know the parent/carer and their current lifestyle, then rather than making any recommendations there and then, you might invite them back for a follow up chat a couple of weeks later. When your behaviour is driven by the parent/carer’s needs for autonomy, competence and relatedness, you may be surprised what can be achieved.
The skills in this module draw on a motivational interviewing approach. For further information about motivational interviewing, you might wish to access the following BMJ learning module.
Below is a short quiz to help you evaluate your learning from this module. You may take the quiz as many times as you like.
Communicating with parents about child weight
Start the quiz
1. Why is communication important when discussing health promotion with families?
a) Because discussing a child’s weight is a very sensitive topic
b) Having a good relationship with parents can help weight-related discussions and outcomes
c) Good practitioner-parent interactions can have positive effects on health and wellbeing
d) All of the above
2. Which of these describes autonomous motivation?
a) Motivation that comes from external influences (e.g. a GP, family member)
b) Motivation that comes from environmental influences (e.g. green spaces)
c) Motivation that comes from the self (e.g. valuing the importance of what you are changing)
d) None of the above
3. If a parent feels pressure from a family member to change their child’s diet, what kind of motivation are they experiencing?
a) Controlled motivation
b) Autonomous motivation
c) Self-determined motivation
d) None of the above
4. Which of the following is not one of the three universal needs of Self-Determination Theory (SDT)
5. Which of the following environments is most likely to enhance the parent’s autonomous motivation?
a) A doctor who greets the parent by their name, asks them about their current lifestyle and praises them for the positive things they are already doing
b) A doctor who emphasises the importance of changing now (otherwise the child will suffer) and gives the parent some advice on how to change
c) A doctor who focusses first on understanding the child’s current lifestyle, then asks permission from the parent to make some suggestions
d) a & c
6. Which of the following are not part of a guiding communication approach?
a) Ask open-ended questions
b) Tell the parent what they ‘should’ do
c) Ask permission to give advice and provide meaningful rationale
d) Offer specific praise and feedback
7. What would be the most appropriate way to support a parent who is resistant to change?
a) Tell them what they need to change anyway
b) Tell them the consequences to theirs and their child’s health if they don’t change
c) Use a guiding approach to structure the conversation so that the parent voices the positives of changing for themselves
d) Use forceful ‘if, then’ language
8. Which of the following is not an “open-ended question”?
a) Talk me through your child’s typical day
b) Does your child eat a lot of chocolate?
c) How does your child feel about their weight?
d) What are your reasons for coming here today?
Thanks for taking part!