motivational treatment times and dry weights tt and dw final .pdf · disclosures: requirements for...

Module 3

MOTIVATIONAL

INTERVIEWING (MI):

TREATMENT TIMES AND

DRY WEIGHTS

The participants at the World Health Organization Adherence

meeting in June 2001 (1) concluded that defining adherence as

“the extent to which the patient follows medical instructions” was

a helpful star ting point. However, the term “medical” was felt to

be insufficient in describing the range of interventions used to

treat chronic diseases. Furthermore, the term “instructions”

implies that the patient is a passive, acquiescent recipient of

expert advice as opposed to an active collaborator in the

treatment process.

Sabate, 2003

OBJECTIVES

Disclosures /Learning Objectives

Brief Overview of Motivational Interviewing Cognitive Dissonance

Ways to Think about Change Problems with each way

The “motivational” way

The Only Way Motivational Interviewing Can Work

What Resistance Looks l ike in Dialysis Patients

Stages of Change as related to Treatment Times and Dry Weight Examples

Change in Thinking Self-Management vs. Self-Care

Tenants of Self-Management

Speaking Suggestions

Overview

Disclosures:

Requirements for successful completion

Conflicts of Interest

Commercial Support

Joint Providers

CEU certificates after August 15, 2017 (Social Workers only)

Learning Objective (s):

To understand the basics of motivational interviewing as related to treatment times and dry weights when interacting with renal patients in the dialysis setting

DISCLOSURES /LEARNING OBJECTIVES

WHAT IS MOTIVATIONAL INTERVIEWING?

http://www.esrdnetwork.org/professionals/social-worker-tools-resources

COGNITIVE DISSONANCE

The state of having

inconsistent thoughts,

beliefs, and attitudes,

especially as relating to

behavioral decisions and

attitude change

Examples

On a diet, but eating out all the

time

Smoking after trying hard to quit

the habit

Just can’t make it to the gym

(workout goals)

Moral “…..People have

problems because of human weakness.”

Medical “…..People have

problems because of physical problems.”

Spiritual “…..People have

problems because of their lack of connection to a higher power.”

Psychological “…..People have

problems because of their inability to learn or emotional issues.”

Social cultural “…..People have

problems because of their environment.”

Biopsychosocial “…..People have

problems because of many reasons.”

WAYS TO THINK ABOUT CHANGE

Focuses on symptoms NOT on the person

Employees: Does not have resources (social, financial, etc.) to adhere to specific policy/requirement (clean uniforms, etc.)

Patients: Does not have resources (social, financial, etc.) to buy foods to be compliant.

Seen as Motherly (Maternalistic)

Seen as Fatherly (Paternalistic

Problems With Using ONLY the Medical Model

PROBLEMS WITH THE MEDICAL MODEL

Used to cope (to fill a spiritual emptiness)

Widely used and most influential in America

Form of SELF-MANAGMENT (positive and negative)

SPIRITUAL MODEL AND THE DIALYSIS PATIENT

“God, I ask that you help

me cope with this new

disease, kidney failure.”

“God, I am angry that this

has happened to me.”

Motherly and Fatherly

Against the Law

Federal law (Title VII of the Civil Rights Act) and the laws of most states prohibit employers from engaging in religious discrimination: making job decisions based on an employee's or applicant's religion or lack of religious beliefs.

Problems With Using ONLY the Spiritual Model

PROBLEMS WITH THE SPIRITUAL MODEL

Problems With Using ONLY the Psychological Model

Facilities don’t have time to dive into patient’s

childhood experiences

Management staff doesn’t have resources to

explore the unconscious mind of employees

Can be viewed as insulting to adults

Not a CMS requirement

Not enough TIME in the dialysis clinic

PROBLEM WITH THE PSYCHOLOGICAL MODEL

Building social, cultural and family relations

Developing social abilities and skills

Aware of how one’s culture affects his/her life Employee:

Millennial employee recognizing that wearing headphones on the treatment room floor is not acceptable

Dietitian realizing that vegetarian Hindu patient needs an alternative source of protein other than meat

Patient: Patient of Hispanic culture realizing that eating

beans at every meal is not acceptable

Patient of African American culture realizing eating high sodium foods at every meal is not acceptable

Vegetarian Hindu patient realizing that the consumption of dairy is not acceptable

SOCIOCULTURAL MODEL

If a patient is more

involved with his family,

has a strong support

group, cultural issues are

addressed, and is

involved in the dialysis

clinic, the *CHANCES of

this patient missing

treatment is reduced due

to acceptable behavior

expectation.

*DOES NOT MEAN THAT IT

WILL SOLVE THE PROBLEM

SOCIOCULTURAL EXAMPLE

“Honey, it’s time

to take you to

your dialysis

treatment.” “Can we watch

a movie after

your treatment,

Dad?”

“Sure.

Lets go.”

Mom Children Dad=Patient

Problems With Using ONLY the Sociocultural Model

Does not stress the importance of objective and

measurable outcomes

Employee

Performance, etc.

Patient

Laboratory Results

High and Low Potassium Levels

High and Low Calcium Levels

High and Low Phosphorus Levels

PROBLEMS WITH THE SOCIOCULTURAL MODEL

This model recognizes the importance of many interacting influences.

*THIS IS THE BASIS OF MOTIVATIONAL INTERVIEWING*

BIOPSYCHOSOCIAL MODEL

Patients have to believe that you possess the following traits:

Non-possessive warmth

Employees/patients can feel received in a human way, which is not threatening. In such an atmosphere, trust can develop, and the person can feel able to open up to their own experiences and their feelings.

Friendly

Truthful

Respect Others

Affirm Others

Empathic

Person-Centered

Supportive

Listen to Others

Transparent (even with bad news)

THE ONLY WAY MOTIVATIONAL

INTERVIEWING CAN WORK

If not→

Result: RESISTANCE

Uremia

Nausea

Vomiting

Altered Mental Status

Conflicts

HOW: Cutting

treatments short

RESISTANCE LOOKS LIKE: PATIENTS

Volume Overload

Swelling of Hands,

Feet, Face

Shortness of Breath

(SOB)

High Blood Pressure

Confusion

HOW: Not following

fluid restrictions

STAGES OF CHANGE

MAINTENANCE

ACTION

PREPARATION

CONTEMPLATION

PRECONTEMPLATION

PROGRESS

RELAPSE

Clinician:

“Hello, Mrs. Smith. How are

you today?”

Patient:

“I already know you are going to talk to me about

missing all last week. I am working on it…My car was

messed up. I have no control over anything!”

Establish rapport, ask permission, and build trust (FRAMES)

Explore

Find what the patient thinks the problem(s) might be?

Sitting “that” long

Missing “something” at home

Cultural issues (not their “idea” of masculine or feminine role, etc.)

Provide factual information about consequences of behaviors

Pros and Cons list

Engage family (if any)

Cognitive dissonance exercises (next slide)

Observations

Interpretation

How patient’s behavior affects others/their environment

Express concern and keep the door open

Document your efforts in the medical record

PRECONTEMPLATION

Patient:

“Gosh, I want to be able to walk into this office, but I am afraid I

can’t give myself shot and I will have to depend on someone

else”

(Ambivalence)

Clinician:

“Let’s talk about what scares you the most about

insulin injections”

(Roll with resistance)

Cognitive Dissonance

Patient:

“Wow, I don’t want to have heart failure….but I am afraid to take

insulin”

Clinician:

“What do you think?” (Ask-provide-Ask)

“I understand that you may not want to start using

insulin (Roll with resistance)….stopping some of your

medications and starting insulin may decrease your

swelling and you get your independence back”

(Cognitive Dissonance – Developing a discrepancy)

Cognitive Dissonance

Clinician:

“Hello, Mr. XX. How are you today?”

Patient:

“I have that paperwork you needed from me. Is

the Dietitian lady here today? I have to tell her

about my visit to the doctor the other day. I’m

not quite steady with those labs, but I’m going

to get there!”

(Taking Action)

Praise progress (even small steps)

Acknowledge dif ficulties

Explore

Pitfalls (high-risk situations like family gatherings with food, etc.)

Ways to make new behaviors permanent

Social supports (do they remain healthy?)


ACTION

Patient:

“I am doing real good. I have kept my labs in order for the

last 6 months. That phosphorus is going down! I am just

trying to maintain!”

Clinician:

“I knew you can do it!”

(Supports self-efficacy)

Praise progress (even small steps)

Encourage patient to tell others his/her success and failures

Accountability

Explore

Find what motivates the patient (grandkids, family, cars, values, etc.)

“So I don’t have to stop fishing, hunting, etc.….”

Ways to make new behaviors permanent.

Develop “triggers” list (in what situations are you likely to be not be

non-adherent)

Social supports (do they remain healthy?)


MAINTENANCE

Patient:

“I know that some foods have more phosphorus than

others. I have been having more sodas and chocolate—it is

so hard to give up everything you like.”

(Ambivalence)

Clinician:

“It is often hard to limit those favorite foods we like the

most”

(Roll with resistance).

“What can you tell me about the risk of high phosphorus?”

Tell the patient “It is okay to be unsure….” or something to

validate that his/her feelings are “normal.”

Explore

Find what motivates the patient (grandkids, family, cars, values, etc.)

“So I don’t have to stop fishing, hunting, etc.….”

Stress that it is his/her choice to make (not the clinicians’)


Pros and Cons list

Encourage the patient to make some self -identified commitment

Repeat back to patient their self -identified commitment

Ask-Provide-Ask (next slide)


CONTEMPLATION

Patient:

“My blood sugars are always on target and my A1C is 6.4.

I work really hard to control my diabetes. I just can’t do it

anymore”

(Ambivalence)

Ask-Provide-Ask

Clinician:

“I know you do (Roll with resistance). Would you like to

look at the side-effects of some of your medications?”

(Ask-Provide- Ask) Patient nods yes.

Patient:

“I am going to keep my word to you and I am planning to

be there next week. I just have to talk to my son to see if

he can bring me or not.”

Establish rapport, ask permission, and build trust (FRAMES)

Explore


Pros and Cons list

Consider barriers and address them as needed (i.e. transportation, childcare, etc.)

Engage social supports

What has worked in the past

Revisit Goals

Start general goals (KDQOL, assessments, etc.) FRAMES

Start behavioral agreement per your internal policies if needed (FRAMES)

Clarify roles (patient and facility)


PREPARATION

Patient:

“I haven’t been missing treatments again! You are lying!”

Clinician:

“I have your records right here, Mrs. XXX! You haven’t been here for 29 days!”

What are your thoughts?

RELAPSE/RECURRENCE

SELF-MANAGEMENT

Dynamic, interactive, and daily process in which individuals engage to manage a chronic i l lness (Lorig & Holman, 2003).

Refers to “the abil ity of the

individual, in conjunction with family, community, and healthcare professionals, to manage symptoms, treatments, l i festyle changes, and psychosocial, cultural, and spir itual consequences of health conditions” (Richard & Shea, 2011)

SELF-CARE

Healthy lifestyle

behaviors are undertaken

by individuals for optimal

growth and development,

or the preventive

strategies performed to

promote or to maintain

health (Richard & Shea,

2011; Riegel & Dickson,

2008)

SELF-MANAGEMENT VS. SELF-CARE

SELF-MANAGEMENT PROCESS: PATIENT

Patient

Focusing on Illness Needs

Learning

Taking Ownership of Health Issues

Performing Health

Promotion Activities

Living with Chronic Illness

Processing Emotions

Adjusting

Integrating Illness Into Daily

Life

Meaning Making

Activating Resources

Healthcare Resources

Psychological Resources

Spiritual Resources

Community Resources

Schulman-Green D, Jaser S, Martin F, et al. (2012) Processes of Self-Management in Chronic Illness, Journal of Nursing

Scholarship 44:136-144

Problem Solving Patient defines

Decision Making Day-to-day decision making in

response to information understood at that moment

Resource Utilization How to find and use resources

Patient and Healthcare Partnerships Provider role is not to diagnose

and treat Module 1

Taking Action Making short-term goals

Module 1

TENETS OF SELF-MANAGEMENT

Self-Management

Problem solving related to

consequences of disease

Patient identified problems

Self-directed behaviors to

improve clinical outcomes

Patient Education

Disease Specific Information

Inadequate control of disease

Compliance with behavior

change

Increasing patient

knowledge does not

always lead to a

behavioral change!

Patients must be able to apply gained information to their REAL LIFE situations

Self-Management

Patient defines the

problem as “they" see it.

If they don’t “see” it as a

problem, roll with resistance

Identify consequences

Document your efforts

Patient outlines how the

problem will be solved,

monitored, and evaluated

PROBLEM SOLVING

Instead of

Milkshake

French Fries, Baked

Potatoes

Hamburger

Try

Small bottled water

Salad, Coleslaw

Regular Jr. Burger (no

cheese); Grilled chicken

sandwich

PROBLEM-SOLVING: “I LOVE FAST FOOD.”

Self-Management: Dollar Store Finds

Salmon (water packed)

Tuna (drained)

Frozen vegetables

Linguine

Pasta Salad (remove vinegar and oil)

Flour tortillas

Sour cream instead of guacamole

Rice

Olive Oil

Canned Shrimp (drained)

RESOURCE UTILIZATION

PROTEIN

WHITE BREAD

Praise

Laboratory results and gold stars

Balloons on chairs (different colors for goals met)

Visual Cues

8-ounce cup

Partnerships

Other service providers

Home Health

Nursing Homes

Doctor’s office(s)

Patient/Family

Accountability

The patient knows their weight when they leave and come to the clinic (difference?)

Pictures for non-readers

Photos for non-English speakers

PREVENTION OF FLUID OVERLOAD

Intentions of Conversation Patient Education Self-Management

What was taught? 1. PO4 target

2. List of high PO4 foods

1. Consequences of PO4

2. How to keep food diary

3. Patient taught foods

they “can” have (health

literacy used- visuals

work best)

How was problem

identified?

1. PO4 out of range 1. Patient identifies

problem as something that

may or may not be related

to disease (i.e. work,

family, etc.)

What is the goal? 1. Goal met with

behavioral change

1. Self-directed behavior to

improve clinical outcomes

(quick and easy low PO4

meals)

PATIENT EDUCATION VS. SELF -MANAGEMENT

SPEAKING SUGGESTIONS

You seem like a reasonable

person. Do you agree (tell

patient or staff to give back

power and control)? How/What

are you going to do to prove

them (whoever they believed has

accused them) wrong?

I trust your

judgement

(Clinic staff)

SPEAKING SUGGESTIONS-CONTINUED

Help me

understand…

It sounds like…

Of the solutions or

resources that have

been presented to you,

which of them seems to

be the most interesting

to you?

Help me understand

how you can help the

patient when you are

so passionate about….

Help identify benefits and

disadvantages of a situation.

The person making the pros and

cons list determines the answers.

A 20-year old smoker is not concerned

with lung cancer as much as playing

basketball

Suppose you don’t

change, what is the

WORST thing that

might happen?

If you make

changes, how

would your life be

different from

what it is today?

What are the

options you have

for life if you don't

take dialysis?

Help identify gaps in behavior for the patient/employee by making a connection between their current behavioral and future goals. Cognitive dissonance may involve confrontation. Rapport must be established before to confrontation.

How does your

missing treatments fit

in with your goal of

wanting to be around

to see your new

grandchild?

How does you

poor attendance

fit in with your

goal of wanting

to go back to

school?

How does your

yelling fit in with

you wanting to

become a Facility

Patient

Representative?

Identifying strengths

How did you get

from where you

were to where

you are now?

You are really

doing well…..

OVERVIEW

Disclosures /Learning Objectives

Brief Overview of Motivational Interviewing Cognitive Dissonance

Ways to Think about Change Problems with each way

The “motivational” way

The Only Way Motivational Interviewing Can Work

What Resistance Looks l ike in Dialysis Patients

Stages of Change as related to Treatment Times and Dry Weight Examples

Change in Thinking Self-Management vs. Self-Care

Tenants of Self-Management

Speaking Suggestions

Overview

Rechelle Brown, LMSW

[email protected]

469-916-3808

EVALUATION LINK

https://www.surveymonkey.com/r/M8GGLHK

EVALUATION LINK

mailto:[email protected]

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Organization, 2001.

Schulman-Green D, Jaser S, Martin F, et al. Processes of Self -

Management in Chronic Illness, J Nurs Scholarsh . 2012;44:136-

144

REFERENCES

motivational treatment times and dry weights tt and dw final .pdf · disclosures: requirements for...

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