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.