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Acknowledgements
Understanding and Improving ICU Patient Outcomes:

Engaging Patients to Participate in Early Mobility

Jennifer E. Stevenson, MPH, PhD Assistant Professor of Rehabilitation Psychology Department of Rehabilitation Medicine University of Washington/Harborview Medical Center

Critical Care Rehabilitation Conference

Baltimore, MD November 16, 2013

Thanks to all of those who have contributed to the concepts and slides presented in this lecture: Chuck Bombardier Stephen T. Wegener Ali Hall Bill Miller Steve Rollnick

Ground Rules and Expectations

Theres no magic bullet Not here to change your clinical style We will mostly operationalize and organize what you already l d k know and dd do Some strategies may fit your style, some may not Take what you can use and leave the rest

How do we engage patients to participate in early mobility?

2 main therapeutic strategies:
Operant Conditioning Motivational M ti ti l Interviewing I t i i

Operant Conditioning Principles Learning that occurs through rewards and punishments of behavior
Rewards cause increased behavior Removal of undesirable outcome can cause decrease in undesirable behavior

Operant Conditioning: Reinforcement Anything that increases/strengthens behavior

Positive reinforcers
Favorable events/outcomes (e.g. praise, direct reward such as ice chips)

Negative reinforcers
Removal of unpleasant events/outcomes (e.g. noise reduction, extubation)

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Motivational Interviewing (MI) Clinical Definition circa 2013

Motivational M ti ti li interviewing t i i i is a person-centered counseling style for addressing the common problem of ambivalence about change

Contrasting Therapeutic Styles

Traditional Fixer Style
Goal-oriented Expert role F Focus on action ti Direct persuasion Give reasons to change Give warnings Clinician talks more

MI Style
Patient-oriented Collaborative F Focus on motivation ti ti Explore ambivalence Elicit reasons to change Elicit concerns Clinician listens more

Recognizing Resistance (Precontemplation?)

Lecturing (directing, warning, preaching, criticizing, approving, interpreting) provides little in the way of motivation Verbal
Arguing Interrupting Denying Disagreeing Minimizing Pessimism Sidetracking

Non-Verbal
Poor eye contact Arms/legs crossed Turned away Volume Facial/body tension Clenched jaw/fists Slouched posture
Miller & Rollnick, 1991

USUAL RESPONSE: ANNOYANCE OR GUILT

Recognizing Ambivalence (Contemplation)

Ambivalence about changing
Yes..but, Im not sure

Recognizing Determination/Action
Decreased resistance or ambivalence Sense of resolve, peace, settled Increased desire or ability to engage Wondering or asking how they could engage

Half-hearted commitment
Ill try to I wish I could

Giving in
If you say so

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Discrepancy
Important motivational factor The distance between current state or status quo and personal goal Goal-status discrepancy is a fundamental driving force for motivation to change (i.e., engage)

Why doesnt discrepancy always and automatically produce change? 1. Goldilocks Principle 2 Lack of self 2. self-efficacy efficacy 3. Evokes feelings of unpleasantness

Interim Summary
Adherence to medical advice can be poor People are not always ready to change Resistance to engage is the clinicians clinician s responsibility A wide variety of clinicians can learn MI to add to their communication skills Motivational interviewing has a strong theoretical and empirical basis

How can I facilitate engagement using operant conditioning and motivational interviewing strategies?

MICU Patient Example: Mr. R

Refusal to participate in prescribed physical therapy Continuous statements of leaving hospital against medical advice

Treatment: Mr. R
Reduced engagement in physical therapy Motivational interviewing was used as an adjunct to CBT
Assisted the patient in identifying the discrepancy between reduced participation and his strong desire to go home to be with [his] family

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Treatment: Mr. R
Reduced engagement in physical therapy and threats to leave AMA
Operant Conditioning Rewards offered for adaptive behavior
Behavior that is reinforced with salient rewards tends to increase while behavior that is not reinforced tends to be weakened Reinforcers for Mr. R included holiday decorations, computer access, and large pizza party

Four Guiding Principles

Resist Righting Reflex Understand Patient Motivation Listen Empower

Processes that Elicit Change

You already have the Steps! Communicating is to MI as stepping is to dancing

Elicit Change
Empowerment Active interest Empathy Feedback Responsibility Active listening Choice Hope/Efficacy Taking Steps Reinforce health Commitment to change

Impede Change
Disempowerment Anger/Hostility Confrontation No Feedback Passivity Silence No choice/Command Powerlessness Inactivity Enabling illness Commitment to status quo

Open Questions
Open questions get the Initial goals might be patient talking, hopefully to communicate: about change (engagement) Acceptance Non-judgmental Non judgmental attitude Using open questions you Not going to control can demonstrate empathy them and acceptance, elicit Elicit values change talk, develop Maybe Good things, discrepancy, etc. not so good things

Affirming
Elicit their strengths and successes Reinforce some strength or small success If they attained part of a goal, focus on what part they accomplished not the part left undone Reframe failure as a partial success or something they can learn from Negotiate goals that have a higher likelihood of success

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Reflective Listening
Demonstrates your understanding Demonstrates empathy, acceptance Mirrors back to the person elements of what they are saying that they may not be aware of Facilitates their self-understanding, insight Decreases resistance

Tips on Reflective Listening

Guess at what they mean Make a statement not a question. With questions inflection goes up at the end. With statements, inflection stays down at the end.
So, you think You are are wondering if It sounds like

Repeat an element (short summary) Paraphrase with synonyms Reflect a feeling

Summarize
Collecting summary-reinforces (elements of) what has been said, lets them know you are following
Reflect, reflect, what else? Summarize

Eliciting Change Talk

DARN Desire to change Ability to change Reasons R t change to h Need to change Commitment to Change I will do that I intend to .. I am going to

Li Linking ki summary-ties ti t together th what h t the th person has just said with earlier material, usually to help them reflect upon ambivalence
On one hand you feel x, y, z and on the other hand you also feel a, b, c

Transitional summary-wrap up the end of a session or move on to another topic

Eliciting Change Talk

Disadvantages of the status quo-What concerns do you have about walking with the ventilator? Advantages of change-How do you think getting out of bed might help people in your situation? Optimism about change-What makes you think you could walk with the ventilator if you wanted to? Intention to change-What parts of physical therapy would you be willing to try?

Brief MI: Importance

How important is it right now for you to ? On a scale from 0 to 10 what number would you give yourself? Why are you at X and not at 1? What would need to happen for you to get from X to (slightly higher number)?
Rollnick, 1999

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Brief MI: Confidence

If you decided to change, how confident are you that you would succeed? On a scale from 0 to 10 what number would you give i yourself? lf? Why are you at X and not at 1? What would need to happen for you to get from X to (slightly higher number)?

Good things, less good things

Ask about good things about bad behavior first Why? Reflect, reflect, summarize Ask about not-so-good things about bad behavior Reflect, reflect, summarize Summarize both sides Ask key question: Where does this leave you?

Eliciting Values and Goals

What keeps you going through all this? What matters most since your illness/injury? What do you look forward to getting back to? Or use a values checklist Andwhere does engaging in physical therapy now fit in with that?

For more information...

Miller W. & Rollnick S. (2013) Motivational Inteviewing: Helping People Change (3rd Ed.). Guilford Press: New York Rollnick S, Miller W, & Butler C. (2008). Motivational Interviewing In Health Care: Helping Patients Change Behavior. Guilford Press: New York.

www.motivationalinterview.org

More Readings

Burke BL, Arkowitz H, Menchola M. The efficacy of motivational interviewing: a meta-analysis of controlled clinical trials. J Consult Clin Psychol 2003;71:843-861. Hettema J, Steele J, Miller WR. Motivational interviewing. Ann Rev Clin Psychol 2005;1:91111. Miller, WR. Rediscovering fire: Small interventions, large effects. Psychol Addict Behav 2000;14:6-18

Thank you!
jesteven@uw.edu