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Motivational Interviewing: A tool for nurses to promote behavior change. Elizabeth Eccles, MS, RN. A primary role of nurse in health care is to help maximize health in patients across their lifespan - PowerPoint PPT Presentation
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Elizabeth Eccles, MS, RN
A primary role of nurse in health care is to help maximize health in patients across their lifespan
For those with chronic medical conditions nurses promote health through education and addressing psychosocial needs: assessment of response to therapies, early intervention, implementing strategies to prevent disease progression, promote restoration on health, and assist in end of life care
Helping patients alter or change their behavior toward more health
promoting behaviors falls into the nursing domain.
Identify needs (based on health status) Information/education (age, literacy,culture
appropriate) – Education is necessary but frequently not sufficient for significant change)
Consider barriers to change Targeted approach(es) to helping change to
healthier behaviors Support Assess
Motivational Interviewing is one approach that has been
shown to be effective in promoting behavior change
through brief targeted interventions and can be
incorporated into clinical care
“Motivational interviewing is a directive, client-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence”
http://motivationalinterview.org/clinical/whatismi.html
4 principals of MI Empathy Support self-sufficiency Roll with resistance Develop Discrepancy
Motivational interviewing is based on a theoretical framework that posits that:◦ Change occurs in a natural process and occurs in
stages◦ Change is affected by both intrinsic and external
forces◦ Motivation is the key to change and motivation is
fueled by a discrepancy between what behavior is present and what behavior is desired
◦ Ambivalence is a part of the process of initiating change and working to resolve ambivalence is the key to processing change.
If change is a natural process which goes in stages…
MI works by facilitating this natural process Assessing where the person in terms of
stage of change will inform the decision of which type of intervention is best suited
You want to keep the person moving toward the change and to have the motivation for change come from the person themselves not the counselor
Techniques are easily adapted to clinical care setting:
ALWAYS client-centered Intended to be brief Present focused Directed
Empathy – being able to see the world through the clients eyes
Support self-sufficiency Roll with resistance Develop Discrepancy
In HIV care has been used as an approach for promoting behavior change for:
◦ Medication adherence◦ Safer sex and risk reduction◦ Smoking cessation◦ Substance abuse◦ Diet and exercise
Establish a “safe” communication environment
Establish respect for the person’s ability to make their own decisions◦ Privacy◦ Non-judgmental approach◦ Empathic vs. non-confrontational messages◦ Communicate caring◦ Communicate confidence in possibility of change
Open ended questions Reflective, active listening Affirmations and positive reinforcement Provide summary statements to verify or
reframe content Communicate confidence Don’t fight resistance (“roll with
resistance”) Don’t argue Don’t take over the process
Ambivalence is the unsettled feeling when one considers the pros and cons and feels drawn to two behaviors.
Passing through ambivalence is a normal part of the process of change
Working with ambivalence is a key to effectiveness of MI. Think of it as “unsticking”.
• PRECONTEMPLATION• CONTEMPLATION• ACTION ( or Preparation/Action)• MAINTENANCE• RELAPSE
As nurses, we work with people at all stages of change. The challenge is to assess where the patient is so that the appropriate strategy can be utilized.
In earlier phases, the work is more to increase motivation
In later phases it is more to strengthen commitment
At this stage, the person has not yet considered changing a behavior
They may not know that change is needed or that there is a problem
They may be defensive about the behavior They may be resistant to considering change At this stage motivation and ambivalence tend to be
low
GOALS of BRIEF INTERVENTION Develop awareness of the problem Don’t alienate; keep them engaged
STRATEGIES• Get more information; ask for elaboration• Listen to concerns; reframe concerns to tie to problem• Develop rapport; express empathy, caring, concern• Provide information• Look for and support motivators
Person has awareness of the issue Has started to consider possible changes
but is not ready to take action Is aware of some benefits and negatives of
making the change Motivation (can be measured by
importance) and ambivalence start rising
GOALS OF BRIEF INTERVENTION• to move toward preparation/action• Increase awareness of options• Stay engaged, active consideration• Person sees more benefits to change
• STRATEGIES• Active listening, reflecting back (concerns, barriers,
intentions)]• Activate person’s curiosity, ideas, concerns• Build discrepancy• Work with ambivalence directly (“roll with
resistance”)• Continue to facilitate motivation
Try to build confidence (find examples of past successes)
Assess the importance of the change to the person (Try to increase the importance)
Assess the person’s confidence in ability to changeTry to increase confidence (self-efficacy)(higher confidence = higher chance of changeKeep the patient in charge of the process,
solutions need to come from themDecision analysis matrix, realistically consider
positives and negatives
Sometimes broken into preparation/action Person moves from considering change to
making concrete plans and implements the plan
GOALS FOR BRIEF BEHAVIORAL INTERVENTION Continue to build confidence Decrease the barriers to change Try to reduce chance of relapse (identify
pitfalls)STRATEGIES Positive reinforcement for making a plan Reduce barriers, engage the patient in anticipation Encourage realistic levels of change Communicate intention to change, gather support
The person has successfully sustained behavior change for 6 months
GOALS FOR BRIEF INTERVENTION Get them to continue focusing on the
behavior change Reduce chance of relapse
STRATEGIES Help prevent minimization; vigilance Reinforce commitment to change “Lapse” is not a relapse; get back on track
quickly Continue to integrate replacement
activities/behaviors
When someone who has changed a behavior reverts to old behavior. Relapse is a normal part of behavior change and should be anticipated
GOALS OF BRIEF INTERVENTION Re-engagement in process Prevent discouragement or shame overwhelming
the process
STRATEGIES Normalize relapse Non-judgemental attitude Explore triggers Back to earlier stages “not starting from the beginning” – past attempts
provide learning
Transtheoretical Model – Prochaska and Diclemente
MI – Miller and Rollnik Mountain Plains ETC, Motivational
Interviewing, August 2003 http://www.motivationalinterview.org/
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