So, when there are barriers to engagement, what do we do about them? There are really four types of barriers, you can think of them as the four As. Since we're doing the four Es, we might as well have four A's as well. The four As include awareness, agreement, ambiguity, and ability. So here, a barrier to the people using an intervention or implementing well is they may not be aware of what they're supposed to be doing. So, be sure to implement some useful education and regularly revisit, talk about the project as much as you can, and enter as many venues as you can so that people are fully aware of it. Agreement is when they feel that there's something about the intervention that they don't think necessarily works well or it's not consistent with their values. This will require group discussion around why they have disagreements with what you're doing. And that will allow you to come up with some ideas on how to address their specific problems or issues. Ambiguity, of course, is when people don't have a sense of what they're supposed to do or it's very unclear what the steps are or whether it applies to every patient in every case and so on. So, this is your opportunity to clarify any kind of ambiguity that there is. Again, through that group discussion, you can usually figure out what the points of ambiguity are. And then ability. Sometimes people don't think that they have the ability to do what's being asked of them. Either they lack the authority or they lack the autonomy to make changes without other people's permission, or they are not sure they have the skills that they need for a new change. So, try to identify any impeding system factors or other training needs and other issues that are causing problems. Eliminate those or try to reduce their impact on people's overall involvement, and that will help your engagement level enormously. There are three areas of beliefs of a clinician or a staff member who is being asked to change to improve patient care. And these include behavioral beliefs. So, they may be saying to themselves, "Does complying with this guideline or this change lead to positive outcomes?" So, they need to believe that this is a positive change and that it will work and is useful. In addition, they have normative beliefs. So these may be around what they think other people expect of them or what they think the system requirements are, what they will be rewarded for, but also what they'll be punished for, socially, interpersonally, financially, professionally. And so, the question asking the question of what are the expectations of colleagues regarding complying with a specific guideline or a specific behavioral request, and then figuring out how to address these normative beliefs within the group. Control beliefs: These are what are the factors that may impede or facilitate guideline compliance or whatever behavioral change you're requesting and the person might be saying to themselves, "How much control do I actually have over these things." So, if they think that there's no way they can do what you've asked because of limitations in their environment, then they will not be engaged. And so, you want to address their control beliefs in your engagement strategy as well. Well, if you keep meeting resistance after you've tried to address the different beliefs of the folks who are asked to change, then we suggest that you tune in to WIFM which stands for "what's in it for me." And this is essentially a framing strategy where you try to think about what the issues are or the reasons for resistance are, and you analyze them and then try to come at it from that approach. So, for one thing, we do know that people tend to appear to resist change. When in fact they're not resisting change, they're resisting a loss that they associate with the change. So this may mean that their responsibilities are going to change or the things that they have control over are going to change, and that's unsettling. So, finding out what it is they're going to miss under the new plan is where you start and talk about the importance of that to them and try to think of ways to mitigate their feelings of loss in that case. It's also important to try to tell what's a real loss and what's a perceived loss. What is a loss that they may be thinking is going to be severe and yet perhaps is not. So, in our blood pressure measurement work, we've noticed that it actually does not take that much more time to measure blood pressure accurately if the people who are doing the measurement are also conducting different tasks while they're waiting for an automated device to conduct three measurements of the blood pressure. And so, if you can get around the fact that they think there's a loss of time by explaining how they can use the time that's being taken on one task differently, you can reconfigure or redetermine the way that they look at that specific change. Further, it will be true, generally speaking, that the perceived loss is greater than the real loss and so you need to try to make that clear. But, the perceived loss will be high when there's low communication. So, if you don't let people know what the truth is in a situation or what your data have shown, they will continue to perceive a significant loss without your assistance. So, we've talked a lot about engagement and of course, what we want to see is people moving from a place of unhappiness into a place of happiness. And we'd like to see them move clear past apathetic into a full-on smile, so that they will be closely engaged with the work that you're trying to do. It will improve your overall outcomes if you have everyone engaged.
