Motivational Interviewing in Action: Skills & Tools to Enhance Change in Physical

Activity Behavior

The Art of Motivational Interviewing

Guest SpeakerLola Coke, PhD, APRN-BC, CNS, FAHA, FPCNARush University College of NursingChicago, IL

Motivational Interviewing takes Practice

• Examine your current patient approach

• Integrate the “Language of MI”into your practice

• It takes practice to be good at MI, counseling or coaching

Motivational Interviewing is:

• Patient-centered but directive.– The patient provides:

• Active decision making• Intrinsic motivation to change• Views and aspirations about behavior change• Choices based on social and economic circumstances

– The practitioner provides:• Structure for discussion, direction and support• Respect, careful listening and guiding• Help with informed choice to change behavior

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General Principles

• Express Empathy– Acceptance and understanding facilitates change– Using reflective listening– Recognizing that ambivalence is normal

• Develop Discrepancy– Let the person express the arguments for change– Change is motivated by discussion between present

behavior and important personal goals or values– Awareness of positive and negative consequences

• Disadvantages of the status quo, advantages of cha nge

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General Principles

• Roll with Resistance– Avoid arguing– Resistance is a signal to respond differently– Alternative change options—mutual decisions– The person is the primary source of answers and

solutions• Support Self Efficacy

– The person is responsible for choosing and carrying out change

– Seek previous experiences that had been successful

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Agenda Setting

• Focus on stress of the clinical situation– Sense of being overwhelmed– Help the person take a broad view of their stress– Alleviates uncertainty and leads to change

• Prioritize and focus on one behavior– “What would you like to talk about”– “How do you want to spend this time together?”

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Steps of Motivational Interviewing

Step 1: Deal with Ambivalence

• Common human experience and stage in the normal process of change

• Feeling two ways about something –“I want to but I don’t want to”

• To explore ambivalence is to work on the problem of being “STUCK” (Miller, 2002)

• “Heightened psychological conflict about choosing between two courses of action”(Rollnick, 1993)

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Step 2: Deal with Resistance

• Resistance is an interpersonal issue that needs to be diminished to move toward change– Patient will bring resistance to the conversation

• Old patterns or habits• Predictive of change or non-change• Categories of resistance behavior

– Interrupting– Negating

• Blaming, disagreeing, excusing, reluctance– Arguing– Ignoring

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Step 3: Build Motivation for Change

• Resolve ambivalence and create discrepancy • Assess confidence and importance• Listen for the patient to begin ‘confidence

talk’– Envisioning, asks questions, less talk about

the problem; more talk about the solution

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Step 4: Determine Readiness

• Measure the degree of motivation and readiness to change

• More likely to succeed if a change feels important and there is confidence to achieve it.

• Need to enhance sense of importance or confidence to increase motivation to change

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Readiness Rulers

• How important is it to you to change this?

0…1…2…3…4…5…6…7…8…9…10Not at all Extreme ly• How confident are you that you can

change this?0…1…2…3…4…5…6…7…8…9…10Not at all Extremely

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Tools of Motivational Interviewing

Communication

• Open-ended questions— No more than three in a row

• Affirmation— Confirming understanding of the underlying meaning of the conversation (nodding, uh huh, tell me more)

• Reflective Listening— Truly listening to what is said

• Summarization: Use few words—the patient should be doing the talking

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Change Talk

• Ask Evocative Questions– “Tell me what would be good about changing?”– “What have you done in the past that worked?”

• Explore Decisional Balance– What are the good things/not so good things?

• Elaborate– Tell me more about your idea to change?

• Looking Back—If there was a time…• Looking Forward---Where would you like to be in 6 m onths

from now?• Brainstorming– What are your ideas to change behavio r?

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Reflective Listening

• Active Listening—What the person is really saying• Levels of Reflection

– Simple Reflection—Repeat what the person has said

– Amplified Reflection• Rephrase• Paraphrase-say in different words or paraphrase the

perceived feeling

– Double-sided Reflection—give both sides of ambivalence—on one hand you feel….but I also heard you say….

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Summary

• The patient will always have ambivalence and resistance.

• Stress, ambivalence and resistance need to be dealt with BEFORE behavior change will occur.

• MI takes practice…start with integrating one step at a time to transition your “practitioner talk” into MI.

• Truly listen to what your patient is saying.

Motivational Interviewing in Action: Skills & Tools to Enhance Change in Physical

Activity Behavior

Wellness Coaching

Guest SpeakerJulie Schwartz MS, RD, CSSD, LD, ACSM-HFSNutri-Well CoachingAtlanta, GA

Fundamental Flaws of Usual Care

• Behavior change should be negotiated NOT prescribed

• Advice, persuasion, even information elicit resistance, as much as they do change

Julie Schwartz, MS, RD, CSSD, LD, ACSM-HFS, Certified Wellness Coach

Julie Schwartz, MS, RD, CSSD, LD, ACSM-HFS, Certified Wellness Coach

Purge yourselves!

You should…You must…

You have to…It’s important that you…

You really need to…

Julie Schwartz, MS, RD, CSSD, LD, ACSM-HFS, Certified Wellness Coach

Words to Reflect

So you feel tired, can you think of a time when you were energized? What was that like?

It sounds like you have a strong desire to begin PA, and you have a lot of other time demands.

You’re wondering if you can maintain the pace of activity. What would it take for you to continue?

Julie Schwartz, MS, RD, CSSD, LD, ACSM-HFS, Certified Wellness Coach

Motivation

• A reason or desire to act• That which gives a purpose and direction

to behavior

Julie Schwartz, MS, RD, CSSD, LD, ACSM-HFS, Certified Wellness Coach

Motivation

There are three critical components of There are three critical components of motivation:motivation:

1.1. Willing: The Importance of ChangeWilling: The Importance of Change

2.2. Able: Confidence for ChangeAble: Confidence for Change

3.3. Ready: PrioritiesReady: Priorities

Julie Schwartz, MS, RD, CSSD, LD, ACSM-HFS, Certified Wellness Coach

What is Wellness Coaching?

•• MIMI

•• Reflective ListeningReflective Listening

•• Appreciative InquiryAppreciative Inquiry

•• Transtheoretical ModelTranstheoretical Model

•• Positive PsychologyPositive Psychology

•• Relational FlowRelational Flow

•• Knowledge, CBT, Social Cognitive Theory,Knowledge, CBT, Social Cognitive Theory,……

Julie Schwartz, MS, RD, CSSD, LD, ACSM-HFS, Certified Wellness Coach

The Coach Approach

� Focus on patient/client strengths � Numerous strategies; unique to each behavior� Patient/client determine SMART behavioral goal

setting� Reframe obstacles into challenges for

opportunities to learn and grow� Blending the coach & expert� New definition of success & Improved success

rate (?)

Tools to help patients evolve from an inactive to an active lifestyle

Julie Schwartz, MS, RD, CSSD, LD, ACSM-HFS, Certified Wellness Coach

Federal Physical Activity Guidelines

O rganiza tio n Durat ion In ten sity Tim es /w eek

3 0 m inu te s M o d era te 5 day s/ w e ek

2 0 m inu te s Inte ns e 3 day s/ w e ek A C SM

A H A

8 -1 0 stre n gth tra ining e xe rc is e s,

8 -1 2 re pe tition s of e a ch 2 day s/ w e ek

150 m inute s M o d era te Pe r w e ek

7 5 m inu te s V ig orous Pe r w e ek H HS

2 00 8 Ph y sica l A c t iv it y G u id e l ine s fo r A m e r ica n s: A g e

1 8 - 6 4

Stre ngth -tra ining tha t w o rks a ll m us cle

g ro ups 2 day s/ w e ek

F or ad di tion al hea lth ben efit s 300 m inute s

150 m inute s

M o d era te

V ig orous Pe r w e ek

C on clu sion: M o de st am oun ts of p hysica l activity w i ll im prove h ea lth a nd cardiore sp ira tory fitne ss of

ina c tiv e pe rso ns; w e ight loss o r w eig ht m a inten ance m ay re quire m ore tha n 30 m inute s of m ode rate

a ctivity m o st day s of the we e k

OR

A N D

O R

A N D

2008 US Physical Activity Guidelines

Recommendations for:

– Adults, Children, Older adults

– Those who are pregnant, have chronic medical problems or disabilities

Julie Schwartz, MS, RD, CSSD, LD, ACSM-HFS, Certified Wellness Coach

InterventionIntervention

•• Goal Setting & ExamplesGoal Setting & Examples–– SpecificSpecific

–– MeasurableMeasurable–– ActionAction

–– RealisticRealistic–– TimeTime

Julie Schwartz, MS, RD, CSSD, LD, ACSM-HFS, Certified Wellness Coach

InterventionIntervention

•• TheThe coordination of nutrition carecoordination of nutrition care part of the part of the Intervention step is especially important with Intervention step is especially important with regard to physical activity. regard to physical activity.

–– -- develop lists of: develop lists of: •• certified clinical fitness professionalscertified clinical fitness professionals

•• certified health fitness professionalscertified health fitness professionals

•• community resourcescommunity resources

Julie Schwartz, MS, RD, CSSD, LD, ACSM-HFS, Certified Wellness Coach

Additional Tools & Resources

• Decisional Balance Sheets• Exercise logs/journals

• HR monitors; accelerometers; step counters

• Internet> info and “how to’s”

Julie Schwartz, MS, RD, CSSD, LD, ACSM-HFS, Certified Wellness Coach

PCNA Online Form: Handout for the FITT Principle and Borg Scale of Perceived

Exertion

PCNA Online Form: Handout for Patients with Heart

Disease

PCNA Online Form: Activity Log

Additional Tools & Resources

• ACSM; EIM• PCNA: www.pcna.net• America on the Move• NIH; NHLBI; NIDDK• American Heart Association• http://www.makethemovementday.org/• The Cooper Institute• You Tube!Julie Schwartz, MS, RD, CSSD, LD, ACSM-HFS, Certified Wellness Coach

Monitoring and EvaluationMonitoring and Evaluation

•• Progress made Progress made

•• Evaluates goals/expected outcomesEvaluates goals/expected outcomes–– Changes in BMI, lean body mass or fat free mass, Changes in BMI, lean body mass or fat free mass,

HTN, Cholesterol, BGHTN, Cholesterol, BG

–– Changes in readinessChanges in readiness

–– SelfSelf--image & selfimage & self--efficacyefficacy

•• Address challenges and obstaclesAddress challenges and obstacles

–– Identify appropriate resolutionsIdentify appropriate resolutions

•• A learning phaseA learning phaseJulie Schwartz, MS, RD, CSSD, LD, ACSM-HFS, Certified Wellness Coach

PCNA Online Form:This clinical tool can be used to evaluate patient coping mechanisms and confidence in ability to

change.

Role Play

• Jane is a 48 year old single mother of a teenaged son. She works as a computer programmer and needs to go back to work when cleared by the doctor. She does not want to attend Cardiac Rehabilitation. She had a single vessel event with angioplasty and stenting. She smokes 2 packs of cigarettes per day, is obese (BMI = 32) and consumes 3 beers a night with her girlfriends after work.

Listen to a Practitioner Interaction with Jane

Role Play Analysis

• Dealt with stress and feelings of being overwhelmed

• Helped Jane develop her own plan for physical activity

• Supportive and provided affirmation for success

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Question & Answer

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