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Review possible causes of patient non-adherence
List examples of effective and ineffective communication techniques specific to patient encounters
Describe key concepts and skills of effective motivational interviewing and goal setting
Apply effective communication and Motivational Interviewing principles in patient encounters
After participating in this learning activity, the participant will be able to …
The failure or refusal to comply: the failure or refusal to conform and adapt one's actions to a rule or to necessity.
Medicinenet: http://www.medicinenet.com/script/main/hp.asp
• Compliance is associated with the medical model• Connotes a 1-way relationship (provider/nurse tells
patient what to do)• Suggests a judgment on the patient, “does not do
what he/she is told”• Leads to frustration on the part of health care staff
IDC-10 codes Z91.19: Noncompliance section (includes specifics such as: financial hardship, dietary, underdosing, intentional versus unintentional, etc.)
We have all done it! But who does it help and where do we go from there?
Usually situation is more complicated (we need to look deeper)
Why do we do it?
RN report example: Mrs. Garcia is a 58-year old Hispanic female who is a noncompliant type 2 diabetic...
Unsure of how to take her
medication
Unable to afford the medication
Afraid of short/long-term
effects of treatment
Confused by the complicated treatment regimen
Unaware of seriousness of not taking (in
denial)
Unable to tolerate the side
effects of medication
Feeling overwhelmed or
depressed
Resistant to txplan due to
cultural/spiritual beliefs
Afraid of what others will think
Mrs. Garcia is a 58-year old Hispanic female with type 2 diabetes who is...
• Implies a passive role, following demands of prescriber
• Clinician dominance
• Goal: obedience to clinician/ staff orders
• Activities are dictated; ptstold what they must do and lectured when they do not
• Noncompliers are judged as deviant, incompetent, lazy, or stubborn
• Resistance is discouraged
• Tools: persuasion, coercion
• Implies an active role, in collaboration with prescriber
• Clinician-patient collaboration
• Goal: patient self-mastery
• Activities are negotiated, plan matched to lifestyle of patient
• Self-motivated decision to stick to treatment advice
• Self-regulation of illness & treatment
• Resistance provides information for adaptation
• Tools: discussion, motivation, negotiation
Gould, E. (2010). P. 291
*P<0.05 when compared to the 80-100% group
Sokol et al. Med Care (2005)
Increasing the effectiveness of adherence interventions may have a far greater impact on the health of
the population than any improvement in specific medical treatments.
World Health Organization (2003)
Communication is PROVIDER/NURSE centered, not PATIENT centered
We tell patient what he/she needs We speak much more than we listen We talk AT the patient, rather than discussing We establish clinical goals rather than considering
what is important to patient We assume our goals should be patient’s goals We do not take time to find out how illness (and
treatment) impacts patient
Resistance to change is seen as a handicap that we need to bury, vs. explore
Dictate (“you need to”) rather than negotiate (“what are you prepared to ...”) behavior change
Communication is rushed and one-sided
Prevalent attitude: Save the patient rather than patients save themselves
Patient’s “readiness to change” is rarely considered
The World Health Organization has made a strong case that medication adherence is based on three
pillars: patient information, motivation, and behavioral skill requirements.
Information
Motivation
BehaviorChange
BehavioralSkills
World Health Organization (2003)
Technique Example
Ordering You are going to have to test four times per day.
Passing judgment I think it is wrong of you not to bring your husband.
Changing subject Let’s not talk about the diet issues right now.
False Hope Don’t worry, everything will work out fine.
Generalizations People always feel better once they get used to exercise.
Defensiveness Come on – no one here would intentionally lie to you.
Arguing How can you say you’re doing better when your A1c …
Aggressiveness It’s your own fault that you are here in the hospital.
Projecting I know how you feel. OR You don’t want to do that.
Dismissiveness You are making a big deal out of nothing.
Sarcasm Go ahead and have the pie; after all, who needs feet?
Technique Example
Active Listening Eye contact, relaxed posture
Observation You seem concerned about the change to your insulin.
Empathy It must be frustrating to have to change your routine …
Sharing Hope I have seen many patients who thought the same thing …
Humor Can diffuse tense situation, encourage, comfort
Silence Allows time to think; silence will encourage response
Provide info. Your A1c test result is 8.9%. The A1c tests tells us …
Clarifying What do you mean by “more that usual”?
Focusing Let’s look at what you ate for breakfast this morning …
Paraphrasing So it sounds like you are saying you are unsure about …
Active Listening Eye contact, relaxed posture
Reflective Listening Listen; avoid interrupting Paraphrase back what patient has said to show understanding: “It
sounds like you . . .” or “What you are saying is . . .” Open ended questions
Requires more than a one-word answer Use “Tell me . . . “What . . .” “How . . .” (avoid “Why” –
judgmental) Nonverbal communication (posture, proximity/position,
eye contact, etc.): biggest influence on message delivery Words used: 7% Tone of voice: 38% Body language: 55%
Affirmation Praise client’s efforts; acknowledge strengths Be genuine; genuine affirmation promotes self-efficacy
Talk to the patient: Avoid judgment Ask “What” instead of “Why” Ask open ended questions
Look for clues; use deductive reasoning skills (RNs are great with these)!
Avoid a rush to judgment (how many times have we been told by others that a patient has poor health due to their non-compliance?)
• In the following examples, select the most likely adherence BARRIER the patient may be facing.
Mrs. Jones faithfully takes insulin and multiple other medicines during the day as prescribed. But every night before bed she gives only half of the prescribed dose. She lives alone.
1. Cost2. Knowledge deficit3. Fear of medication effects4. Regimen too complicated
• In the following examples, select the most likely adherence BARRIER the patient may be facing.
Mr. Smith is willing to check glucose in the morning and before bed. He is open to the idea of mixed insulin BID but not AC/HS. He declines your invitation to participate in group classes.
1. Cost2. Stigma3. Fear of medication effect4. Regimen too complicated
• In the following examples, select the most likely adherence BARRIER the patient may be facing.
Mr. Washington takes the full dose of his generic metformin and glyburide as directed, but cuts his Januvia (non-generic) in half and only takes it when he eats a big meal.
1. Cost2. Stigma3. Fear of medication effect4. Regimen too complicated
“On a scale of 0-10, how important is it for you to … ?”
“On a scale of 0-10, how confident are you …?”
0 1 2 3 4 5 6 7 8 9 10
Readiness to Change is a measure of . . .●IMPORTANCE (“I want to”), AND …
●CONFIDENCE (“I believe I can”)
Case Management Adherence Guidelines (2006)
Group BLow
importance,High
Confidence
Group DHigh
Importance, High
Confidence
Group ALow
importance, Low
confidence
Group CHigh
importance, Low
confidence
Case Management Adherence Guidelines (2006)
Questions to ask: Why a 2 and not a 1? What makes you think this could be a problem? What are the downsides of making a change? What do you think the results of change might
be?
Tools & Interaction: Find what matters to patient Link positive health outcomes to what matters Don’t tell patient he/she is “wrong” Encourage “test your theory” (give it a try)
Case Management Adherence Guidelines (2006)
Adherence Intention is VARIABLEQuestions to ask: What things might get in the way of success? What can you do to overcome these barriers? What tools, skills, knowledge or adjustments do
you need to make this work?
Tools & Interaction: Break down into small short lessons, repeat Use demonstration with teach back Write it down Teach caregivers/supporters Praise patient efforts (build confidence)
Case Management Adherence Guidelines (2006)
“A skillful clinical style for eliciting from patients their own motivation for making changes in the interest of their health”
Introduced by Miller & Rollnick in the early 1990s (for drug & alcohol addiction)
Shown to be successful for behavioral change in many applications (incl. chronic disease)
AMBIVALENCE and/or RESISTANCE are key opportunities to engage
Focuses on assessing and encouraging the patient’s motivation to change, NOT motivating the patient
Rollnick, Miller, & Butler, (2007) and Welch, Rose, & Ernst (2006)
Motivational Interviewing skills are matched with patient's readiness-to-change stage
Create a climate that is safe for patient to share, learn, change OR to challenge, question and reject the provider’s suggestions
Be honest with patients so they can make an informed choice (do not “sugar-coat”/soften or exaggerate)
Rollnick, Miller, & Butler, (2007) and Welch, Rose, & Ernst (2006)
COLLABORATION: Partnership with focus on the client (patient) Shared decision making between client and provider
EVOCATIVE: Understanding client’s goals Connecting behavior change with what client values Use discrepancy between values and current
behavior to evoke reasons for change
CLIENT AUTONOMY: Client ultimately decides what to do We are inherently resistant to being told what to do Provider honors patient’s decision (regardless of own
feelings) Very tough! We must resist the “righting reflex”
(urge to fix things)
Rollnick, Miller, & Butler, (2007) and Welch, Rose, & Ernst (2006)
Roll with Resistance
Express Empathy
Avoid Argumentation
Develop Discrepancy
Support Self-Efficacy
Rollnick, Miller, & Butler, (2007) and Welch, Rose, & Ernst (2006)
Acknowledge that change is always hard for multiple reasons.
Explore why patient may not want to change current behavior… What are the good points about doing just what
you are doing now? Now what are the downsides of making this
change? Now what are the downsides of sticking with
what you are doing now and the upsides to making the change?
PT: I don’t want to take another pill every day. Too much medicine isn’t good for you.
RN: It sounds like are worried about the amount of medicine you are on and that more could make things worse. Is that right?
PT: Right . . . I don’t want that to happen.
RN: I don’t blame you! Let’s talk about the good and bad sides of this medicine. Then you can decide, but at least you will have all the information.
Listen reflectively. Paraphrase or summarize what they have
said to show “you get it” Ask open ended questions. Do not say “I know how you feel” but rather,
“I can imagine that it must be …” Allow patient to “vent” (but not too much)
PT: Everyone makes it sound like it is no big deal, but I am freaking out at all this stuff … change what I eat, check my blood, take this insulin, but watch out for low blood sugar …
RN: I can imagine you must feel very overwhelmed. You have been asked to make a lot of changes to manage this new diabetes and you are sure that you can do it all. Is that right?
PT: Yes, that is exactly right.
RN: Let’s break this down into some more manageable chunks. How about if we identify just the essentials for now?
Foster the TEAM approach (not you vs. them) Do not debate or “prove wrong”When correcting, ask permission to share
information. Assure patient that it is not your plan to force
them into anything but to give them information so that they can make an informed decision that fits them best.
Avoid judgmental language, posture, etc. (ask “what” instead of “why”)
PT: Insulin is terrible for you! It causes kidneys to fail and heart attacks. I don’t want it!
RN: Sounds like you have some serious concerns about the safety of this stuff we want to give you, am I right?
PT: Yeah, that’s pretty much it. CDE: Well let me tell you, your are not the
only one to have those concerns! Can I tell you some things you might not know about this medicine?
PT: I guess so.
This is what helps move the patient from resistance to action.
Identify (or help patient recognize) the things that are important to him/her (goals, values, dreams, etc.)
Highlight how current behavior is in conflict with those items.
Help patient see the disconnect with questions that allow patient to draw conclusions … “How do you think the way your diabetes is now syncs with what you want out of life?”
RN: So, you were telling me about how you’d really like to go to college next year to study music. But you also said that you often forget your insulin and some of the times it makes you feel really sick and end up in the hospital with DKA.
PT: Yea, that’s true. RN: So what are your thoughts about how this
pattern can affect your goal of going to college next year?
PT: Well, I guess that if I really want to go …
While you may be the diabetes expert, recognize the patient as the expert on his/her life and values
Allow patient to suggest next step, plan, goals, etc.
Acknowledge that roadblocks are likely to arise. Let patient know he/she has support and resources
Commend progress (even small) and emphasize that they should feel proud of what has been accomplished.
Respect the patient’s right to go against medical recommendations. Resist the “righting reflex” (this is VERY tough for those in the healthcare profession)
PT: I have been thinking more about what you said about having to give myself shots.
RN: Great. Tell me what you have come up with.
PT: Well, taking insulin shots four times a day just isn’t going to be possible, but I think I might be able to do once a day.
RN: Sounds like a good place to start. How about if I show you how to do it? Then you can try yourself. In the meantime, let me talk to the doc and see what once daily options might work.
Setting goals are an important aspect of self-care
Start with some short term goals
Patients may need assistance in setting goals
Goals may need to be adjusted from time to time
Goals should be patients' goals, not RN/MDs’
Work on as few goals goal at a time as possible
Goals should be “S.M.A.R.T.” . . .
Specific• What do you expect to have happen?• Break large goals down into smaller ones
MeasureableHow will you know you are making progress?Use concrete measuring tools.
AttainableIs the goal realistic with your current resources?Aim for a goal that will not cause undue stress.
Relevant• Is this goal important to you personally?• Choose goal that will make a real difference.
Time-defined• How much time is scheduled to work on it?• Set a date on which you plan to complete goal.
Allow patient to direct communication; listen more Turn off the “fix-it” impulse; facilitate patient in
driver’s seat Always consider patient’s readiness to change Use effective communication techniques
Reflective listening Open-ended questions Non-verbal communication Affirmation
Use MI Skills Roll with Resistance Express Empathy Avoid Argumentation Develop Discrepancy Support Self-efficacy
Assist patient with setting S.M.A.R.T. goals
48 y/o female, admitted for leg abscess, just diagnosed with type 2 DM while in the hospital.
A1C is 11.6% (just measured in hospital)Discharge Medication regimen: Metformin 1000
mg BID and 12 units Lantus QHSWhen you greet her and ask how she is doing
today, she breaks down into tears. She states that she is not doing well; she feels like there is no way she can handle all this.
She states that her mother died of diabetes and she does not think she can do this.
68 y/o male, history of type 2 diabetes (13 years); admitted for acute renal injury; A1c: 9.2%
When you talk to him about his diabetes he tells you he checks his blood sugar at home three times a day and takes his insulin and pills as directed. States his blood sugar is always between 80 and 120.
He cannot tell you what his doses are but says he has them written on a paper at home.
Later admits that sometimes he forgets to check his blood sugar and to take his insulin because he gets too tired at night and falls asleep in front of the television.
To make small talk, he tells you about his golf game (he is proud of his skill and accomplishments on the golf course)
19 y/o female, history of type 1 diabetes (7 yrs). Admitted for DKA (third time in 12 months)
A1C is 13.1% Mother is there. She tells you, “I am through! It
does not matter what I do, she just does not care. I tell her over and over what will happen to her if she keeps this up; maybe she will listen to you.”
Patient does not seem to want to engage. Seems despondent, even depressed. She does perk up when her friends come to visit and talk about a concert they are all planning to go to next month.
Home regimen: Basal/bolus (MDI) therapy. Levemir BID and NovoLog TID AC with a carb ratio of 8 and correction factor of 40. (no pump/CGM)
Case Management Adherence Guidelines, version 2.0 (June, 2006). Case Management Society of America Accessed 7 Feb 2012 from http://www.cmsa.org/portals/0/pdf/CMAG2.pdf
Gould, E. (2010). Medication adherence is a partnership; medication compliance is not. Geriatric Nursing, 31 (4), 290-298. Morisky DE, Green LW, Levine DM. Med Care. 1986;24:67-74. (find in Case Management Adherence Guidelines, 2006)
Rollnick, Miller, & Butler, (2007). Motivational Interviewing in Healthcare. Guilford Press.
Sokol et al. (2005). Impact of medication adherence on hospitalization risk and healthcare cost. Medical Care 43(6), 521-530.
Welch, G., Rose, G., and Ernst, D. (2006). Motivational interviewing and diabetes: What is it, how is it used and does it work? Diabetes Spectrum, 19,1, 5-11. Accessed from http://spectrum.diabetesjournals.org/content/19/1/5.full on January 12, 2014.
World Health Organization (2003). Adherence to Long-Term Therapies: Evidence for Action. Accessed 7 May 2012 from http://whqlibdoc.who.int/publications/2003/9241545992.pdf
