Facilitator Training Workshop

Group introductions

Name Organization & location Clinical background Stroke experience Previous Living with Stroke experience Expectations of workshop

Thoughts I cannot teach anybody anything. I can only make them

think.• Socrates (Greek philosopher, 470-399 BCE)

Change your thoughts and you change your world. • Norman Vincent Peale (American clergyman, 1898-1993)

The greatest discovery of my generation is that a human being can alter his life by altering his attitudes of mind.

• William James (American philosopher and psychologist, 1842-1910)

The only kind of learning which significantly influences behaviour is self-discovered or self-appropriated learning – truth that has been assimilated in experience.

• Carl Rogers (American humanist psychologist, 1902-1987)

Objectives To understand Living with Stroke (LWS) and its

objectives To understand particular challenges involved in

working with stroke survivors To focus on facilitation rather than clinical teaching To practice facilitation To develop familiarity with LWS materials To develop confidence in facilitating LWS

Housekeeping

Workshop structure: 1 day Phone Washrooms In your package: Expense sheets Presentation handout Detailed information on facilitation and group dynamics

• HSFO LWS Facilitator Notes• Facilitation: A Brief Overview• Group Dynamics Overview• LWS Kit• Evaluation Form

Agenda Morning

• LWS introduction• Facilitation basics: LWS-

offered separately if needed• Module 1• Module 2

Break• Module 3• Module 4

Lunch• Module 5• Module 6

Break• Module 7• Module 8• Wrap Up• Adjournment and

Evaluation

Living with Stroke introduction

Need for program

Greater reduction in quality of life than expected Problems five years after rehabilitation Family caregivers have increased health risks Opportunity to intervene to improve health-

related quality of life Networking opportunity for stroke survivors and

caregivers Increase awareness of community resources

Program description

6-8 week interactive workshop program • 1-2 module/week: develop group dynamics and skills• 2-hour workshop: maximum duration to prevent

fatigue

Focus: education and support, not clinical care Held in a community setting Survivor of stroke plus caregiver Optimal size: 8-12 participants

Program goals

To improve stroke outcomes by:• Providing stroke survivors and caregivers with

tools • Assisting stroke survivors and caregivers to cope

• Facilitating engagement in adjustment and

recovery

Program modules Module 1: Understanding Stroke Module 2: Physical Changes and Challenges Module 3: Swallowing and Nutrition **Module 4: Cognition, Perception & Communication **Module 5: Emotions: Focus on Depression Module 6: Activities and Relationships **Module 7: Reducing the Risk of Stroke **Module 8: Moving Forward

Flow of modules 5-10 minutes: Introduction and follow up Group ground rules 10-15 minutes: DVD 30-40 minutes: Individual stories from survivors and caregivers 15 minutes: Break 15 minutes: Teachable moment (based on stories) 10 minutes: Questions and stories 15 minutes: Teachable moment (based on previous questions)

and weekly commitment to change (goals): building self efficacy 5 minutes: Conclusion and suggested handouts

Room set-up

Room for adaptive equipment Chairs in semi-circle or circle with table Data projector, laptop and speakers

• Visibility and sound quality

Flip chart, black board or white board• Appropriate markers or chalk

Table at side • Refreshments, handouts, other resources• Signage if required

Facilitator tools Provided

• Marketing and recruitment materials • Manuals• National and regional resources• DVDs• Forms

Facilitator responsibility• Program marketing• Participant recruitment • Local resources: list and identify before program start • Visual aids, handouts and learning tools• Refreshments

Facilitation basics: Living with Stroke

How does a facilitator differ from

a clinical educator?

Promoting engagement Engagement

• Psychological energy: attention, interest, recognition of relevance

• Importance: Supports participation in recovery Facilitator

• Encourages participation in learning or change• Draws out knowledge and ideas

Provides appropriate structure for productive interactions Focuses on effective group processes Empowers group to discuss, think and act together Releases responsibility for outcome to participants

See Facilitation: A Brief Overview

Avoiding pitfalls Pitfalls

• Prevent group from achieving its objective • Arise externally or from within group• Potential pitfalls common• Anticipate and develop strategies to address them

LWS addresses barriers to engagement • Misinformation• Maladaptive health-related beliefs and attitudes• Practical barriers

Important: Barriers prevent problem-solving, learning and use of health information

Program principles

Psychoeducation Group dynamics Building self-efficacy Group process Eliciting the story Using the story for teaching

Psychoeducation

Health teaching and outcomes Knowledge vs behaviour change

• Why do we persist with unhealthy behaviours when we know the dangers?

• How can you bridge the gap between knowledge and behaviour change?

Psychoeducation

Health teaching and outcomes Personal relevance and applicability of information

• Increases learning • Influenced by attitudes and beliefs

Facilitators need to: • Understand health-related attitudes and beliefs• Reduce barriers by addressing attitudes and beliefs• Promote attitudes that facilitate adaptation • Use cognitive-behavioural strategies• Promote practice, problem solving and learning

Group dynamics

Forming Storming Norming Performing Re-forming

Key for LWS: Balance group process and individual needs

Building self-efficacy

Self-efficacy• Belief in one’s capability to master a new skill• Perception of competence to make a desired

change• Conscious awareness of ability to be effective, in

control• Confidence in ability to be successful

An important facilitator responsibility • How do you build your own sense of self-efficacy in

facilitating LWS?

Building self-efficacy

Self-efficacy: Central concept for LWS • Gradual, small changes• Failures and successes• Persistence and encouragement

LWS promotes the development of self-efficacy so participants come to believe they can make behavioural changes that promote their own recovery and health

Group process

Facilitator focuses on effective processes to create structure for effective interactions

• Providing methods and tools • Ensuring equal voice for participants

Meeting participants’ focus on content• Topics of discussion

Content vs process exercise

John is very distressed. He hasn’t seen his grandchildren since the stroke because he can’t drive anymore.

In this example, How could the facilitator focus on process? What

would be the impact on John and the group? How could the facilitator focus on content? What

would be the impact on John and the group?

Content vs process exercise

Andrew’s story Andrew has high blood pressure (145/105

mmHg) but he doesn’t like taking medication, so he only takes it occasionally. At the same time he wants to reduce his risk of another stroke. He says he quit smoking, maintains a healthy weight and walks half an hour daily.

How could the facilitator use Andrew’s story for teaching?

Participant stories

Sharing stories critical to program success Eliciting story is an important facilitator skill

• Asking the right questions• Identifying issues of personal importance• Uncovering barriers to change• Never giving advice or communicating criticism

WEEK 1Module 1: Understanding stroke

Module 1 Purpose Introduces program to stroke survivors and caregivers Creates a positive environment Encourages participating (sharing stories) Creates a foundation of knowledge about stroke in

general Introduces risk factor reduction – medication compliance Introduces the concept of making a commitment to

change (weekly goals)

Module 1

Facilitator focus• Supporting group formation • Eliciting the stories

Module 1 review • Facilitator introduction• DVD: Survivor stories

Integrating

• Participant stories Facilitator control of process (time) Specific challenges

Module 1

Challenges in working with stroke survivors Group formation and impact of stroke General strategies to encourage discussion Encouraging reluctant participants Managing talkative participants

Module 1

Supporting group formation • Creating an effective group from diverse

participants• Compensating for stroke impact

Remember, even mild impairments can:• Affect participation in and benefits derived from

LWS • Have implications for group process• Compromise attention, organization, concentration

Module 1

General strategies to encourage discussion • Open-ended questions• Continuation techniques and nonverbal cues

(nods)• Series of specific questions to obtain more detail

See Facilitator notes for more details

Module 1

Encouraging reluctant participants• Determine reason • Open-ended questions • Non-verbal encouragement, wait • Summarize and prompt speaker• Questions to focus on story• Summarize to focus health teaching

Module 1

Managing talkative participants • Use additional questions to refocus response• Respectfully interrupt and move to more relevant

topic • Tactfully redirect discussion• Return to agenda• Request other contributions • Use closed ended multiple-choice questions

Module 1 Module review

• Teachable moment • Use and incorporate information from stories • Educate about stroke• Use questions to engage participants• Elicit the story• Medications (adherence, not clinical) and healthy living

recommendations • Record responses: barriers, issues • Teachable moment• Discuss recommendations• Risk factor reduction

Module 1 Module review (cont’d)

• Program objectives and commitment to change• Record program objectives: What would you like to

get out of this program and what can this group and program do to help you meet your goals?

• Record weekly commitments to change: What change can you try over the next week to improve your health?

• Conclude session with review of learning and commitments

• Evaluation

Module 1

Module review (cont’d)• Local resources and handouts• Connecting to resources a program objective• Facilitator responsibility to prepare list

Support for recovery needed for self-care and reintegration

• Stroke survivors apply learning from rehabilitation• Family and caregiver provide supports for recovery• Link to community resources: important role

Module 1 small group exercise

When asked to tell his stroke story, one participant says, ”I thought this workshop was about moving forward—I don’t want to talk about the stroke. I feel I’ve put it all behind me.”

Module 1 small group exercise

Questions1. What are the pitfalls here?2. How could you engage him in the group

process? 3. What strategies can you develop to address

potential concerns?

Module 1 small group exercise

The workshop has reached the stage of committing to make a change that will reduce the risk of another stroke. You ask, “What change can you try over the next week to improve your health?”

One stroke survivor, who has participated throughout the workshop says “I don’t think I can do that.”

Module 1 small group exercise

Questions• How do you respond to this comment? • What questions can you use to identify barriers to

change?• What role could the other group members play in

helping this participant engage in committing to change?

• How can you turn this negative comment into a learning exercise for the group?

WEEK 2Module 2: Physical Changes and

Challenges

Module 2

Purpose• Address the most visible changes as a result of

stroke – the physical limitations• Discuss the importance of physical activity for

both recovery and risk reduction• Teach goal-setting skills: key for all modules

Module 2 Review ground rules Review previous weeks presentation Share goals, accomplishments, challenges Distribute resources pertinent to this week DVD: Recovery and physiotherapy – 13 minutes Participants share stories Facilitator educates about stroke and physical

limitations Participant stories about impact of physical limitations

Module 2

Facilitator educates about taking control and importance of physical activity

Goal setting skills Participants commit to one way of increasing

physical activity over the next week Facilitator concludes session Evaluation

Module 2

Unrealistic expectations common Managing unrealistic expectations

• Convert to problem-solving exercise• Recognize the difference between hopefulness

and denial• Safety implications

Module 2

Module 2 review • Goal-setting

Introduce SMART-c goals• Specific• Measurable• Attainable• Realistic• Timely• confidence

Module 2

S = Specific Defines action and emphasizes desired outcome Make a goal specific by answering:

• What do I want to accomplish?• What am I going to do?• How am I going to do it?

“I will exercise daily by walking” is more specific than “I will develop healthy habits”.

Module 2M = Measurable Measure progress toward goal by achieving small steps Make a goal measurable by including criteria for

success:• How will I measure progress toward my goal?• How will I know when I reach my goal?

“I will increase my daily walking duration by 10 min every week” is a measurable goal.

Achieving measurable progress toward a goal is a strong motivator

Module 2

A = Attainable Attaining goals should be a challenge but not impossible Feelings of success help to maintain motivation Make goals attainable by answering the following

questions:• Is it possible for me to achieve this goal?• What help, if any, do I need to achieve this goal?

“I will increase my daily walking duration by 10 min every week until I reach 30 min a day” is an attainable goal for many people.

Module 2

R = Realistic Based on existing knowledge, skills, or lifestyle Achievement may require change Make a goal realistic by designing it to be

difficult but not impossible:

“I will increase my daily walking duration by 10 min every week until I reach 30 min a day and I will continue this for 4 weeks.”

Module 2

T = Timely Timeframes ensure progress is made toward achieving

goals Make a goal a real task by attaching an achievable end

date:• When will I accomplish specific steps in this goal?• When will I accomplish the entire goal?

“I will increase my daily walking duration by 10 min every week until I reach 30 min a day and I will continue this for 4 weeks. I will reassess my exercise program after 4 weeks.”

Module 2

c = Confidence Final component in validating goal Confidence in achieving goal on a scale of 1-10 If confidence low, look at ways of raising it to 8-10

• What could prevent me from achieving my goal? • Why do I feel I may not achieve my goal? • What ideas or strategies can I try to increase my

confidence in achieving my goal? • What help do I need?

Break

WEEK 3Module 3: Swallowing and Nutrition

Module 3

Purpose• Reviews swallowing problems as a result of stroke• Presents the importance of healthy eating to

overall health, stroke recovery and risk reduction• Discusses coping with eating and dietary changes

Module 3 Review group ground rules Review last week’s module Share goals, accomplishments, challenges DVD – Professional Video, Dietician Participants share stories Facilitator educates on risks, incidence of dysphasia page

39 Participant Manual Participant stories about feelings and coping with changes

in eating

Module 3 cont.

Teachable moment: Facilitator discusses importance of positive strategies and solicits suggestions for dealing with restriction, maintaining social contacts and eating a healthy diet

Participants agree to try one way of improving diet over the next week

Facilitator summarizes session Evaluation

Dietary Sodium and Blood Pressure

PPP Dietary Sodium and Blood Pressure Go to : www.hypertension.ca -Click on view tools -Then click on 2009 Sodium Public

Education Sodium Slide Kit 45 slides developed for public education Easy to understand, menu makeovers, quiz

Module 3 exercise

During the workshop on Module 3, participants share their feelings about changes in their eating, and what this means to them. One participant says “I’m eating nothing but mush.”

Module 3 exercise

Questions1. How would you respond to this person?2. How could you use the group to support the

person?3. What questions could you ask to better

understand this person’s feelings?

Week 4 and 5

Module 4Cognition, Perception and Communication

Module 5Emotions: Focus on Depression

Module 4

Purpose• Introduce cognitive and perceptual problems• Review issues related to communication• Understand impact of changes • Develop ways of compensating for these changes

Module 4 Review group ground rules (only if necessary) Review goals, accomplishments, challenges DVD: Living with aphasia - 15 minutes Neuropsychologist video available Individual participants share stories about changes in their life Overview of cognitive, perceptual and communication problems Facilitator fills in information gaps about the importance of

these problems and coping strategies Participants set goals for the week Facilitator summarizes session

Module 4 Facilitation exercise: Suggest strategies for each of

the following: • Maximizing attention and comprehension• Compensating for age-related cognitive changes• Aiding comprehension and depth of understanding• Facilitating learning and memory• Teaching and discussion• Asking effective questions• Encouraging participant with cognitive impairments• Improving recall• Changing topics

Module 4 exercise

A participant is telling her story when she repeats herself several times. Her spouse says “For pity’s sake, you’ve said that three times!” There is laughter in the group.

Module 4 exercise

Questions1. As a facilitator, how do you defuse the

situation?2. How can you address the topic of memory

loss without causing further embarrassment?

3. What strategies do you use to get back on track with story telling?

Module 4 exercise

Cognition, perception and communication are sensitive topics. Participants are asked at the beginning of the session to tell their stories. One participant has some aphasia and finds it difficult to participate fully.

Module 4 exercise

Questions How do you ensure that this person has an

opportunity to share his story? What could you do to facilitate communication

between this person and the rest of the group? What assumptions do you think other group

members may make about this person? How do you address these assumptions?

WEEK 5Module 5: Emotions: Focus on depression

Module 5

Purpose• Focuses on the emotional changes experienced by

caregiver and stroke survivor after a stroke: anger, grief, loss, depression and anxiety

• Explains why emotional reactions may occur and discusses ways of addressing them

• Discusses the importance of participants who may be clinically depressed seeing their physician for evaluation and appropriate treatment

Module 5 Review last weeks module Share goals, accomplishments, challenges DVD: Emotional issues 15 minutes Participant stories about emotional reactions, depressions, its

impact and coping Facilitator fills in information gaps about the connection

between stroke and mood changes, validates experiences Facilitator fills in information gaps, discusses importance of

differentiating normal emotions from depression Participants agree to try one way of coping with mood changes

over the next week Facilitator summarizes session Evaluation

Module 5

Manage participant emotions like any other effects of stroke

Strategies • Naming or labelling • Understanding and empathy• Normalizing emotion• Using opportunity for teaching• Providing support • Using respect to support progress

Module 5

Facilitator exercise and challenges• Review last week’s commitment to change • Incorporate caregiver perspective• Deal with depression with sensitivity

Module 5 review • DVD: Emotional issues• Teachable moment: Educate about depression

Impact of depression on overall health Importance of seeking help if depression suspected Review Geriatric Depression Scale pg 71 PM Be sensitive to perceived stigma

Module 5 Distress and suicide risk Be alert to potentially dangerous situations requiring

immediate attention• Thoughts of suicide• Indicators of problems managing medications

Stories may include distressing and intimate issues unrelated to stroke

• Provide empathy • Refocus discussion on parts of story relevant to module

Lunch

WEEK 6Module 6: Activities and Relationships

Module 6

Purpose Adjustment to life after a stroke Prevention of social isolation and depression

by promoting engagement Importance of social and family relationships Participation in both familiar and new

activities Community reintegration

Module 6 Review of last weeks module Share goals, accomplishments, challenges DVD: Family support and caregivers -16 min Individual participants share stories about changes in activities

of daily living and instrumental activities of daily living Facilitator fills in information gaps about the need to do things

differently, the meaning and emotional impact Participant stories about changes in relationships and activities Facilitator fills in information gaps, discusses importance of

engaging in life, and in important relationships and activities Facilitator summarizes session Evaluation

Module 6 exercise

Millie becomes a grandmother

Module 6 exercise

Questions How would you use this clip to engage the group? What makes this video clip so emotional for you? What do you think Millie is struggling with the

most? Why? If you showed this video clip in your group and

you saw tears, as a facilitator, how would you react?

WEEK 7 and 8Module 7: Reducing the Risk of

StrokeModule 8: Moving Forward

Module 7

Purpose• Focus on practical ways of adopting a healthy

lifestyle Healthy diet Physical activity Stress reduction

• Focus on implementation and necessary knowledge

Module 7 Concludes the workshop series Review last weeks module Share goals, accomplishments, challenges Review of stroke risk factors and warning signs of stroke DVD: Reducing the risk of stroke 10 min Participant stories about barriers to following health care advice Teachable moment: Practical approaches (nutrition labels, Canada

Food Guide, physical activity) Participant stories: Stress and coping, unhealthy coping strategies Teachable moment: Facilitator fills in information gaps, teaches

healthy coping Participants agree to try one healthy stress reduction method Facilitator summarizes session

Module 7 Facilitator exercise and challenges

• Follow-up on previous week’s goal • Caregiver perspective • Practical tools for healthy living and risk reduction

Module review• DVD: Reducing the risk of stroke • Teachable moment

Educating about lifestyle change and stress reduction Identifying tools Developing strategies to overcome barriers

• Weekly commitment to change: try a healthy stress reduction technique

Module 7: Group Exercise

The group just finished listing recommendations they were given regarding lifestyle and medication. The facilitator recorded the list on a flipchart. The facilitator asks the participants to share any barriers they anticipate in making the recommended changes.

Module 7: Group Exercise cont.

Questions:1. What key barriers to change may emerge

and list strategies to address barriers?

WEEK 8Module 8: Moving Forward

Module 8

Purpose• Recognizes progress participants have made in:

Understanding stroke Developing strategies to adapt to their new circumstances Developing the skills and confidence to change behaviours

Focuses on making and accomplishing future commitments to change on their own

• To get support (form a support group?)• To continue recovery and reduce stroke risk• To reclaim pleasures in life

Module 8 Facilitator introduction DVD: Life after stroke – 6 min Participant stories and program benefit Stroke Busters PPP Teachable moment: Facilitator validates learning and

reviews importance of active role in recovery Teachable moment: Facilitator fills in information gaps,

consolidates ways of addressing future challenges Support group discussion Discussion of future changes (goal setting) and exercise Conclusion

Module 8

Facilitator exercise and challenges• Setting the stage for the future• Encouraging group to continue to meet or join

support group

Module review • Follow up last week’s commitment to change • DVD: Life after stroke 6 min

Module 8

Module review (cont’d) • Participant stories: meaning of program and changes in

Knowledge Thinking Attitudes Behaviour

• Teachable moment: Summarize learning and movement

Passive to active Not understanding stroke impact to addressing problems Experiencing stress to taking personal control

Module 8 Module review (cont’d)

• Revisit question: What would you like to get out of this program and what can this group and this program do to help you meet your goals?

Ask if they achieved their goals

• Participant stories about current strategies and approaches to future challenges

• Teachable moment: Opportunities for change Partnership with healthcare providers Connecting with community resources and programs Control of health, healthy choices and relapse mgt Warning signs of stroke; risk reduction

Module 8

Module review (cont’d)• Support group benefits: Stroke Recovery Canada• Review of process for making and achieving

commitment to change (goal setting)• Conclusion

Thank everyone for participating Congratulate participants Reinforce achievements Collect evaluation forms

Module 8 exercise

The group is in its final session and the facilitator is wrapping up the eight module series. A participant states, “I want to come to the next Living with Stroke session. When is it?”

Module 8 exercise

Questions1. How would you respond to this request?2. Why do you think this person wants to

repeat the program?3. What behaviours would indicate how the

participant is feeling?4. What options are available to the

participant in feeling connected to the community?

5. What feelings do you think you would have at the end of program?

Break

Living with Stroke Implementation

Local resources

Heart & Stroke Foundation Community centres Municipal parks and recreation departments Church or senior groups Day hospital programs Local chapters of organizations Professional care organizations Local libraries Support groups

Planning your program

Organizational issues• Who needs to be involved in program planning?• What is the process for program planning and

approval?• How long does it take?• Who will take responsibility for different aspects of

the program?

Planning your program

Logistic issues • Where can the program be held (accessibility,

chairs with arms, room for tables, washrooms, etc)• What equipment is available (television, DVD,

blackboards, speakers, flip charts and markers)?• When should the program be held (time of day or

evening, time of year [winter not optimal], day of week)

• Transportation assistance

Planning your program

Questions to answer:• How should the program be marketed and advertised?• What other healthcare professionals should be informed

of the program (and possibly involved in recruitment)?• How much in advance of the program should

recruitment begin?• Will refreshments be provided?• What educational tools would be useful?• What handouts are available and when

should these be given to participants?

Planning your program

Develop project team for program Identify team leader Assign responsibilities Develop work-back schedule Schedule project team update meetings Implement

Conducting your program

General requirements• Wheelchair accessible building, washrooms and room • Adequate lighting• Comfortable chairs with arms• Comfortable room temperature• Clear signage• Room for coats, boots, personal belongings• Quiet area: Minimal distractions • Room to walk around• Room for adaptive equipment

Conducting your program Workshop room requirements

• Chairs and tables in semi-circle to support participation• DVD player, speakers and television

Sound and visual quality Learn to operate

• Flip chart, blackboard or white board availability (+ markers) Record participant responses Use for teaching

• Tables for refreshments and handouts • Room for other resources and teaching tools

Conducting your program

Organize yourself• Have contact information for participants available

(telephone reminders?)• Use a notebook to record participant commitments

to change for follow up • Have a system to follow up on participant requests

for information or healthcare contacts etc• Assemble visual aids• Assemble handouts and other teaching tools

A note on refreshments

Providing refreshments for the break encourages socializing

Consider possible swallowing difficulties when choosing snacks:

• Serving yogurt or applesauce is usually safe, even for individuals with swallowing problems

• Providing water is important: it assists those who must take medications at specific times

• Having coffee and tea available for caregivers and stroke survivors who can drink thin fluids

Pacing workshops

Suggested times for module sections are only guidelines

Expected to change depending on the group composition, knowledge, interests and level of participation

Need to monitor workshop pacing during each session

Conduct all workshops in planned order

Networking

Network with the training group as your plan your program

Get support and build your confidence Brainstorm ideas Address concerns and questions

Contact Information

Tammy Tebbutt (519) 749 4300 ex 2605 tammy.tebbutt@grhosp.on.ca

Sandra Goodyear (519) 749 4300 ex 2735 sandra.goodyear@grhosp.on.ca

Thank you facilitators! Good luck with your workshops!