Motivational Interviewing (MI) for Nurses

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1 Today we will cover: 1) Compare and Contrast two models of change: Facilitating Behavior Change Using Motivational Interviewing (MI) for Nurses Robin Monson Dupuis, LCSW, SAC Manager Outpatient Aurora Behavioral Health Services Health Belief Model Stages of Change Model 2) Understand how the Stages of Change Model is the foundation for using Motivational Interviewing (MI) to help patients feel accepted where they are, not judged. 3) Learn and practice the skills of MI. Aurora Health Care, Inc. Health Belief Model (HBM) Developed in 1950 s by social scientists in the U.S. Public Health Service in order to understand the failure of people to adopt disease prevention strategies. (Rosenstock, 1966) HBM Assumes: If a person believes they are being threatened by an illness or disease Plus They believe in that a recommended health behavior or action is effective Equals The person will change their behavior to become more healthy! Sounds simplistic HBM, continued Ultimately, what we do to stay healthy (or return to health) is based on a benefit/cost analysis: 1.) perceived susceptibility: a person s feelings of personal vulnerability to an illness. 2.) perceived severity: a person s feelings on how serious it is to contract an illness, or the severity of their current illness. 3.) perceived benefit: how beneficial is the course of action to prevent/cure illness? 4.) perceived barriers: a person s feeling regarding obstacles to acting on a health recommendation. 5.) cue to action: internal or external stimulus to trigger action. 6.) self-efficacy: level of person s confidence to be successful in the action. 1

2 Limitations of HBM: Does not account for individual attitudes, beliefs that dictate a person s acceptance of a health behavior. behaviors that are habitual or addictive (smoking, overeating, abuse of pills, alcohol, etc.) choices we make that have nothing to do about our health but are all about being socially accepted. environment or economic factors. assumes everyone has access to the same information on illness/wellness. assumes cues to action are present in people s lives to encourage them to act. assumes that awareness = readiness to change. Self-Efficacy and MI (Motivational Interviewing) The importance of respecting a person s sense of self-efficacy cannot be over emphasized in using MI. Self-efficacy: The strength of one s belief in one s own ability to persist and to succeed with a task or goal The belief that I am able to have control over and have power over MY practice of a particular behavior (both positive and negative behaviors.) We need to hold ourselves accountable to making meaningful connections with our patients that helps them and enhances their sense of self-efficacy. Stages of Change Model Developed in late 1970s by Prochaska and DiClemente who studied smokers who quit on their own contrasted with smokers who required further treatment. It was determined that people quit smoking if and when they were ready to do so. 5 stages of change we cycle in and out of: 1.) Pre-contemplation no interest to change in the next 6 months. Lack awareness or underestimate pro of changing, over emphasize cons of changing. Acknowledge and Accept. 2.) Contemplation intending to change in next 6 months. Awareness there may be a problem, a more thoughtful weighing of pros and cons, ambivalent about change. Meet them where they are. Stages of Change Model (cont d) 3.) Preparation ready to change in next 30 days. Start to take small steps, identifies goals on own. Opportunity to encourage self-efficiency. 4.) Action - Have recently changed behavior (within the last 6 months) and intend to keep moving forward. Normalize challenges, improve coping, support commitment in time and energy. 5.) Maintenance sustained change. Recover from lapse, relapse, collapse, resume forward steps. Maintain intent to avoid the undesired behavior. Anchor what is working. 2

3 Stages of Change Model AUTOBIOGRAPHY IN FIVE SHORT CHAPTERS by Portia Nelson Pre Maintenance Enter Contemplation Relapse Contemplation Action Preparation I I walk down the street. I fall in. I am lost...i am hopeless. It isn't my fault. It takes forever to find a way out. II I pretend I don't see it. I fall in again. I can't believe I am in this same place. But it isn't my fault. It still takes a long time to get out. III I see it there. I still fall in... it's a habit... but, my eyes are open. I know where I am. It is my fault. I get out immediately. IV I walk around it. V I walk down another street. Motivational Interviewing Technique Motivational Interviewing (MI) Technique Initially developed for use in the substance abuse and mental health fields, it is now an evidenced based approach used in general health care, executive and wellness coaching, athletic coaching and training to enhance an individual s motivation to change. It encourages us as healthcare providers to not view our patients as non-compliant or resistant, but respecting where they are in their stage of change and starting with them there. 4 Fundamental Activities to utilize in MI: Engage an individual in a way that creates rapport, and shows them our empathy for them. Explore where the individual is currently at in their readiness to change, using a non-confrontational, non-adversarial, non-judgmental approach. Persuasion is not an effective method for addressing ambivalence. Help the individual explore and voice their own ambivalence/fear about change by helping them weigh the pros & cons of the proposed change. Clarify the barriers to change. Promote the individual generating solutions/ideas themselves. Their buy-in is greater. Help strengthen the individual s own internal motivation as opposed to them being externally motivated. 3

4 OARS or OARN Skills: O: Use open ended questions Allows patient to tell their story, encourages them to do more talking and you to do more listening. A: Affirm what they have already done or tried; recognize their strengths (In other areas as well), display empathy for their situation. - Success and mastery of behavior change in one area of one s life (parenting, friendships, job, hobby) can generalize to success and behavior change in other areas (health and wellness!) Ex: The experience of competently asking for a new entrée can translate to successfully accomplishing walking 3X s this week. OARS or OARN Skills: continued R: Use reflective listening Demonstrates that you are listening and trying to understand the situation from their point of view. Gives them the opportunity to hear their own thoughts and feelings reflected back to them. S: Summarize the key points of the conversation to make sure you and the individual are on the same page. Close conversation with a plan of action. N: Normalize, if they are ambivalent This communicates that their worries, fears are not uncommon, and that they are not alone in their ambivalence. Close conversation with an offer to help patient address barriers to change. Two tools to assist your conversations: Assess readiness to change using Readiness to Change Ruler Assessing readiness is very static and can change rapidly from day to day Use 1-10 scale Ask them to predict tomorrow? Day after? Next week? Next month? In 6 months? Neutral/Curious pros vs. cons exploration Helps them to self-identify what are the benefits to continue behavior and what will be some costs to continue behavior. Start with the cons first. These questions help to identify what will happen if they choose not to change. Give feedback, not advice, using the Change Plan worksheet Research shows simple advice does not work well because most people don t like being told what to do Motivational Interviewing Suggest adding a new behavior, rather than stopping a behavior. Explore what is most important to change? second most important? difference between the two? easiest to change? greatest chance for success? 4

5 Motivational Interviewing. Resistance in this exploration means for you to move on, retreat, return to rapport building. Emphasize their freedom of choice (remember self-efficacy!) Threatening, fear based approaches don t work in changing unhealthy behaviors. Components of MI in action: Sample Questions: Use open-ended questions that demonstrate concern for patient: Q. If I could see this (topic) through your eyes, what would I see? Assess readiness to change: Q. On a scale of 1 10 with 10 being very ready, how ready are you to explore (topic) and how you see it affecting your health? Objectively share from patient s labs, results, exam, etc. then elicit reaction: Q. What do you make of these results? Q. What would your family member make of these results? Components of MI in action: Sample questions For patients not ready to change, or who are unconcerned: Q. Is there anything else you want to know about (topic)? Q. What would it take to get you to consider thinking about a change in (topic)? For patients who are unsure about change: Q. What are the things you like about (topic)? What does it do for you? Q. What are the things you don t like about (topic)? What concerns do you have about it? For patients who are ready to change: A. Here are some options for (change, treatment). What do you think would work best for you? Provide support and referral. Sources Motivational Interviewing in Health Care Settings, Opportunities and Limitations. K. Emmons and S. Rollnick, American Journal of Preventive Medicine, Vol. 20, No 1, Motivational Interviewing: Preparing People for Change. 2 nd Ed. New York, NY, Guilford Press, Health Behavior Change: a Guide for Practitioners, S. Rollnick, P. Mason, C. Butler, Edinburgh Scotland: Churchill Livingston, California Healthcare Foundation website, Helping Patients Manage Chronic Conditions Toolkit, June Robinson, P. and Reiter, J., Behavioral Consultation and Primary Care: A Guide to Integrating Services, Springer, Adultmeducation.com. Motivational Interviewing 101, The Advisory Board Company, Nursing Executive Center,

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