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
 Principal care giver: Doctors.  Professionals are experts.  Patients are passive.

COLLABORATIVE CARE
 Principal care giver: Patients themselves.  Professionals are experts about disease. 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  Information and skills are taught
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SELF-MX EDUCATION  Skills to solve patient-identified problems are taught

Usually disease-specific Assumes that knowledge creates behavior change Goal is compliance Teachers are health care professionals Didactic

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

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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)

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Differences
HE Practitioner & Client BRIEF MI MI

Active expert- Counselor-active Leading passive participant partner-partner recipient Sometimes Seldom Never

Confrontation/ Challenging Empathetic Style Information

Sometimes Provide

Usually Exchanged

Always Exchanged to 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 Questions Reframing & Summarizing Roll with Resistance Exploring Ambivalence “Importance” Scale Elicit Benefits Elicit Barriers Elicit-Provide-Elicit Patient decides 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 selfmanagement 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.

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