Introducing Motivational Interviewing in Nursing: Enhancing Patient Motivation for Change

1. An Introduction to Motivational Interviewing for Nursing Sofie Champassak, Ph.D. & Denisse Tiznado, Ph.D. November 6, 2017 SDSU CNSA

2. A little about us Sofie Champassak, Ph.D. Denisse Tiznado, Ph.D. • Clinical training • VA Settings with an emphasis in primary care, Women’s health, addictions, PTSD • Children’s Mercy Hospital • Community health centers • Research Training • Smoking cessation • HIV medication adherence • Provider perspectives on smoking, PrEP and sexual health • Clinical training • VA Settings with an emphasis in geropsychology, neuropsychology, primary care, addictions, Women’s health • Community health centers • Research Training • Cognitive functioning and quality of life in stroke survivors and their caregivers • Everyday functioning in people with schizophrenia

3. Today’s Overview • Some underlying theory and data • What makes people change? • Definition and “spirit” of Motivational Interviewing approach • Principles and strategies for using the motivational approach

4. What’s This All About? • So much of health is now about behavior • What are the most common health issues you see in your setting? • How do you address these health issues with your patients? • Health education and advice are not effective • Health care providers need empirically supported methods of counseling

5. What’s This All About? • Motivational Interviewing (MI) is a method of brief counseling (includes conversation and communication about change) • MI is collaborative (person-centered, partnership, honors autonomy, not expert-recipient) • MI is evocative, seeks to call forth the person’s own motivation and commitment

6. History of MI • Origins in treatment of substance use disorders • Intentional alternative to traditional confrontational treatment • Most research still in addiction field • Diffusion into health care, corrections • Newer diffusion into mental health, education, dentistry, social work, nursing • Research and implementation efforts expanded to many fields and situations that require behavior change • > 20,000 Research Studies, 5,000 publications per year, > 40 books

7. Empirically Supported Theory of Motivation Self-Determination Theory (Deci & Ryan, 2000) • “Autonomous” or internal motivation produces more change -e.g., “The reason I exercise is because I want to be healthy.” • “Autonomy Support” by practitioners produces more change -e.g., “I want to help you to figure out what you want for yourself; it’s your decision.”

8. Goals of MI Approach • Create a set of conditions that enhances an individual’s own motivation and commitment for change • Help patient focus on their situation in a non-judgmental way • Explore and resolve ambivalence • Assist a person to move through the stages toward a successful sustained change

9. Motivational “Spirit” • A collaborative way of working with the patient that honors and respects their autonomy and self-direction • Belief that people inherently move in the direction of positive growth in right climate

10. The Underlying Spirit of MI Collaboration MI Spirit Acceptance Compassion Evocation

11. Motivational “Spirit” • Collaboration • It’s a partnership, not expert/recipient • Evocation • Elicit patient’s motivation and commitment, resist the righting reflex • Direct patient to examine and resolve ambivalence with open-ended questions • Compassion • Demonstrate genuine concern and an awareness of the patient’s experiences • Acceptance • No persuasion! • Patient articulates and resolves ambivalence

12. Acceptance Absolute Worth Affirmation Autonomy Accurate Empathy

13. Normal Human Responses to a Listening/Evocative/Empathic Style • Approach Talk more Liking Engaged Come back • Affirmed Understood Accepted Respected Heard Comfortable/safe Empowered Hopeful/Able to change • Accept Open Not defensive Interested Cooperative Listening

14. Normal Human Responses to the Righting Reflex (Teach/Direct) • Invalidated Not respected Not understood Not heard Angry Ashamed Uncomfortable Unable to change • Resist Arguing Discounting Defensive Oppositional Denying Delaying Justifying • Withdraw Disengage Disliking Inattentive Passive Avoid/leave Not return

15. Which people would you rather work with? Open Cooperative Listening Engaged Active Empowered Hopeful Likes you Defensive Oppositional Arguing Disengaged Passive Powerless Dislikes you

16. Four Processes of MI Bridge to Change Strategic Centering

17. Four processes of MI • Engaging is the process of establishing a helpful connection and working relationship • Listen to understand the dilemma and values, apply MI spirit, use OARS

18. Basic MI Skills (OARS) • Open-ended questions:asks for elaboration to gain understanding, helps with agenda setting • Affirmation: recognition of efforts and strengths from past or present, supports patients to follow-through • Reflection:statements feeding back to patient your understanding, elicits more info until understanding is clear, patient feels heard • Summary:checks in with your understanding, allows opportunity for correction

19. OARS: Open Ended Questions Get the patient talking: • “Tell me how you feel about your weight/eating habits.” • “What are your thoughts about your smoking?” • “I know you may be afraid you’ll be lectured about having to eat healthier. I won’t do that, but I would really like to know how YOU feel about your eating habits.”

20. OARS: Open Ended Questions • Questions that can’t be answered with “yes/no,” “place,” “thing,” “date” or any single word! • Request elaboration – “Tell me more. What else?” • Explores: Patient’s needs, values, expectations, experience, feelings, beliefs, priorities, importance, confidence • Evocative, collaborative, honors autonomy • STRATEGY AND DIRECTION!

21. OARS: Affirmations Affirmations can be used to: • Demonstrate support, hope, or caring • Recognize patient’s strengths and efforts • Builds self-efficacy - orients people to their resources • Must be personal and genuine, used with cultural sensitivity • Appreciation of patient’s attributes, effort, perseverance, showing up • REMEMBER: STRATEGY AND DIRECTION!

22. OARS: Affirmations Examples Demonstrate support, hope, or caring “This is hard for you.” Show appreciation for values “Being honest is important to you.” Recognize strengths “Once you make up your mind, you really stick with it.” Reinforce behaviors, successes, and/or intentions “You are really trying to make a change.”

23. OARS: Reflective Listening • Statements, not questions (voice goes down) • Starts with….. • So…. • Sounds like….. • You…. • Can amplify meaning, feeling, ambivalence, values/goals • Affirms and validates • Can be used strategically to keep the patient thinking and talking • Much more effective than questioning • May take more time (use wisely)

24. Reflections: Foundational Skill • Repeat: The simplest, but often powerful • Rephrase: Close to the same words, but substitutes in synonyms • Paraphrase: A major restatement, meaning is reflected with new words. Adds to and extends what the patient said • Reflection of feeling: A paraphrase that emphasizes the emotional dimension

25. Reflective Listening Examples It sounds like: • You have mixed feelings about changing your diet… • You feel overwhelmed when... • This has been tough for you... • You’re not ready to….

26. Process 1: Engaging • Engaging is the process of establishing a helpful connection and working relationship • Questions to consider during Process 1 • How comfortable is this patient talking to me? • How supportive and helpful am I being? • Do I understand the patient’s perspective and concerns? • How comfortable do I feel in this conversation? • Does this feel like a collaborative partnership?

27. Process 2: Focusing 2. Focusing is the process by which we develop and maintain a specific direction in the conversation about change • Strategic agenda setting, finding a focus, providing information and advice (with permission)

28. Process 2: Focusing Agenda Setting Eliciting the patient’s agenda • “What would you like to talk about today?” • “What brings you here today?” • Offering a menu • Asking permission to discuss your agenda • Would it be all right if we also talked a bit about . . .?

29. Process 3: Evoking 3. Evoking involves eliciting the patient’s own motivations about change and lies at the heart of MI • Change talk: any speech that favors movement in the direction of change, linked to a particular change goal

30. Change Talk – DARN CATs Preparatory Change Talk - DARN • DESIRE to change (want, like, wish . . ) • ABILITY to change (can, could . . ) • REASONS to change (if . . then) • NEED to change (need, have to, got to . .) Mobilizing Change Talk - CATs • Reflects resolution of ambivalence • Commitment (intention, decision, promise) • Activation (willing, ready, preparing) • Taking steps

31. Strategies to Elicit Change Talk • Evocative questions • “In what ways does this worry you?” • “How would things be better if you changed?” • Rulers for importance, confidence, readiness • Elaboration • “You said you really enjoy drinking. What do you like about it? What do you not like about it?” • “Tell me about how eating poorly affects your health.”

32. Eliciting Change Talk(& Developing Discrepancy) Evocative questions • Disadvantages of the status quo: • What worries you about your current situation? • What do you think will happen if you don’t change anything? • Advantages of change: • How would you like things to be different? • What would be the advantages of making a change? • Optimism about change: • What personal strengths do you have that will help you succeed? • Intention to change: • I can see you’re stuck at the moment, what’s going to have to change? • What would you be willing to try?

33. Eliciting Change Talk (& Developing Discrepancy) Evocative questions (cont.) • Querying extremes • In the long run what concerns you the most? • How much do you know about what can happen? • If you were completely successful in changing how would things be different? • Looking back and forward • Do you remember a time when things were going well for you? What has changed? • How do you want things to be 10 years from now? • Exploring Goals and Values • What things are most important to you in life? How do these relate to your current behavior?

34. Importance Ruler Not at all important Extremely important 0--1--2--3--4--5--6--7--8--9--10 “On a scale of 0-10, how important is it to you to stop smoking?” • “Why is it a (x) and not (a lower number)?” • Reflect

35. Confidence Ruler Not at all important Extremely important 0--1--2--3--4--5--6--7--8--9--10 • “On a scale of 0-10, how confident are you that you can stop smoking?” • “Why is it a (x) and not (a lower number)?” • Reflect

36. Process 4: Planning 4. Planning encompasses both developing a commitment to change and formulating a concrete plan of action (not necessary for MI) • The bridge to change, negotiating a change plan, consolidating commitment

37. Process 4: Planning It’s time for the Planning process when: • there is sufficient engagement • a clear shared change goal • motivation for change • Often a “testing the water” strategy such as summary and key question

38. Key Planning Questions • When asking for commitment to change • Where does this leave you now? • What happens now? • Where do you go from here? • When asking for setting specific goals • How would you like things to be better? • What specifically are you hoping to change? • What do you see as the first change?

39. Key Planning Questions • When asking for development of a plan • What have you considered doing? • What’s the first step • What’s worked for you before? • When asking for commitment to a plan • When do you start doing this? • What do you think about doing this plan? • What worries you about the plan?

40. Process 4: Planning • Planning is an ongoing process Use the patient’s expertise • You don’t have to provide all the answers • Balance with appropriate use of professional expertise • Three scenarios: • Clear plan • Menu of options for how to proceed • Unclear (Moving from general to specific)

41. The 4 processes are somewhat linear ... • Engaging necessarily comes first • Focusing (identifying a change goal) is a prerequisite for • Evoking • Planning is logically a later step • Engage  Focus  Evoke  Plan

42. … And also recursive • Engaging skills (and re-engaging) continue throughout MI • Focusing is not a one-time event; re-focusing is needed, and focus may change • Evoking can begin very early • “Testing the water” on planning may indicate a need for more of the above

43. When Giving Information and/or Advice • Ask permission • Emphasize autonomy, diminish expert role • This may or may not fit your situation… • Many patients have said… • Give menu of options

44. Giving Information and Advice: A Simple Framework Elicit, Provide, Elicit • E - Tell me what you know about… the importance of always taking your medications as prescribed? • P - That’s true. May I share some other information you may find interesting about that? Research shows/many of my patients tell me… • E - What’s your reaction to that?

45. How do I know if I’m doing good MI? • When I hear myself saying statements that emphasize and/or support apatient’s autonomy: • “It’s completely up to you whether you want to do this or not. “ • “It’s your choice whether you want to make a change.” • “You know yourself best.”

46. How do I know if I’m doing good MI? • MI Adherent • Asking permission before giving advice or info • Affirmations • Emphasizing control, autonomy • Proving support with statements of sympathy or compassion MI Non-Adherent • Advising without permission • Confronting • Directing by giving orders or commands

47. Comments? Questions? Concerns?

48. Parting Thoughts • MI is a skill that takes practice – try out little strategies at opportune moments • Be prepared for a low success rate (psychosocial and environmental factors are powerful) • Focus on having a meaningful dialogue rather than the outcome • The relationship is key – don’t be afraid to plug away visit-to-visit

49. Resources • http://www.motivationalinterview.org/