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Motivational Interviewing

Application in Clinical Practice
APN Elizabeth Ho Moon Liang
MN (Singapore), BSc Nur (Australia)

 Singapore Disease Management Conference (10 May 2008)
 Case Management Forum (25 July 2008)
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. ”
Chan, B. and Molasiottis (1999).
Journal of Advanced Nursing, 30 (2), 431-438.

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.
Evolving HCP-Patient Relationship
The Goal of CDM is NOT Cure but
Maintenance of Pleasurable and Independent
Living
TRADITIONAL CARE COLLABORATIVE CARE
 Principal care giver:  Principal care giver:
Doctors. Patients themselves.

 Professionals are experts.  Professionals are experts
about disease.
 Patients are passive. Patients are experts of
their lives.
 Shared responsibility.

Bodenheimer, Lorig, Holman and Grumbach, 2002. JAMA, 288(19), p.2469 – 2475.
Evolving HCP-Patient Relationship

PATIENT EDUCATION SELF-MX EDUCATION
 Skills to solve patient-identified
 Information and skills are
taught problems are taught
 Skills are generalizable to all
 Usually disease-specific
chronic conditions
 Assumes that knowledge  Assumes that confidence yields
creates behavior change
better outcomes
 Goal is compliance  Goal is increased self-efficacy
 Teachers are health care  Teachers can be professionals
professionals
or peers
 Didactic  Interactive

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
Principles of MI

“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
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)
Differences

HE BRIEF MI MI
Practitioner &
Active expert- Counselor-active Leading
Client
passive participant partner-partner
recipient

Confrontation/
Sometimes Seldom Never
Challenging

Empathetic
Sometimes Usually Always
Style
Exchanged to
Information Provide Exchanged develop
discrepancy
Audio Recording (Health Education)

Pass “Judgment”

Provide unsolicited advice

Confrontation

“Prescribing” Directions

Mostly closed-ended questions

Nurse “talk time” > Patient “talk time”
Audio Recording (Brief MI)

Open-ended “Importance” Scale
Questions
Elicit Benefits
Reframing &
Summarizing Elicit Barriers

Roll with Resistance Elicit-Provide-Elicit

Exploring Patient decides
Ambivalence Directions

Patient “talk time” > Nurse “talk time”
Importance, Confidence or Readiness?

Willing: The Importance of Change

Able: Confidence for Change

Ready: Matter of Priorities

MI Course for Facilitators Slides by Ken Reniscow year Jun 2007
MI Tools and Techniques

Eliciting 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
Exploring 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 Resistance
 Reflective listening
--- Respond to content, feeling and meaning
 Empathizing
In A Nutshell

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.

Agree
Commit
Involve
Participate
Undertake

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.