motivational interviewing: application in clinical practices
DESCRIPTION
Singapore polyclinics experience presented at:-- Singapore Disease Management Conference (10 May 2008)-- Case Management Forum (25 July 2008)TRANSCRIPT
Motivational Interviewing Application in Clinical Practice
Singapore Disease Management Conference (10 May 2008) Case Management Forum (25 July 2008)
APN Elizabeth Ho Moon LiangMN (Singapore), BSc Nur (Australia)
Outline
Relevance and Importance of Motivational Interviewing (MI) in Chronic Disease Management
Principles of MI and its Adaptation Audio demonstration of Health Education
versus Brief MI Application of MI techniques and tools in
outpatient clinic session
Chronic Disease Management
Agree??
If the patient knows more about his disease/ condition, he or she will be more likely to
initiate or sustain a healthy behaviour.
If the patient knows more about his disease/ condition, he or she is more likely to be
compliant.
If the patient knows more about his disease/ condition, he or she is more likely to have better
health outcomes.
• Mrs Fatimah, 65 years old.• Never been to school.• Generally happy about life.
“ Missy, I’ll try. I’ll try. ”
• Mr Rajman. 50 years old. • Study till secondary school.• Work as a taxi-driver.• Generally unhappy about life.
“ I know everything already. I’ve heard so many times already.
You don’t need to tell me. ”
The relationship between diabetes knowledge and compliance among Chinese with non-insulin dependent
diabetes mellitus in Hong Kong
This study examines the relationship between diabetes knowledge and compliance among Chinese with non-insulin dependent diabetes
mellitus (NIDDM) in Hong Kong. A cross-sectional design was used to collect data through structured self-report interviews based on validated
scales assessing diabetes knowledge, compliance behaviours and demographic data. The Diabetes Knowledge Scale was used to sample
knowledge in the major areas of basic physiology of diabetes and general principles of diabetes care. Compliance level was assessed by using the Compliance Behaviour Questionnaire, inspection of patients’ feet and the value of HbA1c. A convenience sample of 52 Chinese with NIDDM receiving out-patient diabetes care participated in the study on a voluntary basis. Descriptive and correlational statistical analyses were
used to analyse the data.
Chan, B. and Molasiottis (1999). Journal of Advanced Nursing, 30 (2), 431-438.
The findings indicated that there was no association between diabetes knowledge and compliance.
There was a gap between what the patients were taught and what they were actually doing.
Most of the patients gained higher marks on factual knowledge on diabetes but lost marks on the application of knowledge to their real life situations.
Chan, B. and Molasiottis (1999). Journal of Advanced Nursing, 30 (2), 431-438.
Principal care giver: Patients themselves.
Professionals are experts about disease. Patients are experts of their lives.
Shared responsibility.
Principal care giver: Doctors.
Professionals are experts.
Patients are passive.
The Goal of CDM is NOT Cure butMaintenance of Pleasurable and Independent
Living
Bodenheimer, Lorig, Holman and Grumbach, 2002. JAMA, 288(19), p.2469 – 2475.
TRADITIONAL CARE COLLABORATIVE CARE
Evolving HCP-Patient Relationship
PATIENT EDUCATION Information and skills are taught Usually disease-specific
Assumes that knowledge creates behavior change
Goal is compliance
Teachers are health care professionals
Didactic
SELF-MX EDUCATION Skills to solve patient-identified problems are taught
Skills are generalizable to all chronic conditions
Assumes that confidence yields better outcomes
Goal is increased self-efficacy
Teachers can be professionals or peers
Interactive
Evolving HCP-Patient Relationship
Bodenheimer, Lorig, Holman and Grumbach, 2002. JAMA, 288(19), p.2469 – 2475.
Motivational Interviewing
Introduced by Dr Miller
Addictive behaviors
Recently used in chronic disease management
Based on framework of Transtheorectical Model of Change
Challenges the stages of Change as fluid rather than fixed
“A directive, client-centered counseling style for
eliciting behavior change by helping clients to
resolve and explore ambivalence” (Rollnick and Miller, 1995 cited in Miller, 1996, p.839).
Express Empathy
Develop Discrepancy
Roll with Resistance
Supporting Self-Efficacy
Principles of MI
MI Adaptation
Brief Motivational Interviewing is NOT Motivational Interviewing.
Brief MI retains the principles of MI
Requires only 15 to 20 minutes to execute.
Possible to do it in the outpatient setting
Alternatively, techniques/ tools of MI can be incorporated into Health Education (HE)
Practitioner & Client
HE
Active expert-passive recipient
BRIEF MI
Counselor-active participant
MI
Leading partner-partner
Confrontation/ Challenging
Sometimes Seldom Never
Empathetic Style
Sometimes Usually Always
Information Provide ExchangedExchanged to
develop discrepancy
Differences
Audio Recording (Health Education)
Pass “Judgment”
Provide unsolicited advice
Confrontation
“Prescribing” Directions
Mostly closed-ended questions
Nurse “talk time” > Patient “talk time”
Open-ended Questions
Reframing & Summarizing
Roll with Resistance
Patient “talk time” > Nurse “talk time”
Exploring Ambivalence
“Importance” Scale
Elicit-Provide-Elicit
Elicit Benefits
Elicit Barriers
Patient decides Directions
Audio Recording (Brief MI)
Willing: The Importance of Change
Able: Confidence for Change
Ready: Matter of Priorities
Importance, Confidence or Readiness?
MI Course for Facilitators Slides by Ken Reniscow year Jun 2007
Eliciting Change Talk: Using ScalesEliciting Change Talk: Using Scales
0 5 10
“On a scale of 0 to 10, how ready are you to quit smoking?”
Ask backward question. (Eliciting Benefits) Ask forward question. (Eliciting Barriers) Ask what does it take. (Eliciting Solutions)
MI Tools and Techniques
MI Tools and Techniques
Exploring AmbivalenceExploring Ambivalence
Summarize and reframe patient’s conflicting values and behavior. Emphasize Values Discrepancy.
“You are concerned about your health affecting your job in the long run and yet there is difficulty to engage in some form of healthy behavior change, where does this leave us now?”
Roll with ResistanceRoll with Resistance
Reflective listening --- Respond to content, feeling and meaning Empathizing
In A Nutshell
The notion of “HEALING”The notion of “HEALING”
We are usually convinced more easily by
reasons we have found ourselves than by
those which have occurred to others.
Pascal 1623-1662
Issue of Engagement
Engage -- To occupy the attention or efforts of (a person or persons). -- To win over, involve or draw into.
AgreeCommitInvolve
ParticipateUndertake
Retrieved from http://dictionary.reference.com/browse/engage on Jun 2008
Should Knowledge precede Engagement?Should Engagement precede Knowledge?
Chick and Egg Philosophy
More than a Technique. It’s a STYLE.
References
Chan, B. and Molasiottis (1999). The relationship between diabetes knowledge and compliance among Chinese with non-insulin dependent diabetes mellitus in Hong Kong. Journal of Advanced Nursing, 30 (2), 431-438.
Bodenheimer T, Lorig K. and Holman H. and Grumbach K (2002). Patient self-management of Chronic Disease in Primary Care. JAMA, 288(19), p.2469 – 2475.
Burke, B.L., Arkowitz, H. and Dunn, C. (2003). The efficacy of motivational interviewing and its adaptations: what we know so far. In W.R. Miller and S. Rollnick, Motivational interviewing – preparing people for change, pp. 217 - 250. New York: The Guilford Press.
DiClemente, C.C. and Velasquez, M.M. (2002). Motivational interviewing and the stages of change. In W.R. Miller and S. Rollnick, Motivational interviewing – preparing people for change, pp. 201 – 216. New York: The Guilford Press.