Motivational Interviewing: Keeping behavior change real Jan Booth, RN, BSN, NC-BC Living Well Nurse Coaching Faculty, International Nurse Coaching Association Falls Church, VA

Objectives At the conclusion of the presentation session, participants will be able to: Discuss the advantage of motivational interviewing over the traditional approach to health behavior change.  Identify four guiding principles of motivational interviewing. Identify the Stages of Change that determine a person's readiness to change behaviors. Discuss four motivational interviewing techniques nurses can use to help people create behavior change plans.

Disclosure I disclose the absence of personal financial relationships with commercial interests relevant to this educational activity within the past 12 months.

What is Coaching? Coaching Shift from compliance to collaboration Teaching Counseling Advising Advocating Coaching Client takes the lead Mode of support & exploration & curiosity Collaborative vs. directive Time-limited Goal-oriented Builds on strengths & readiness Shift from compliance to collaboration

Coaching Skills Active listening & Open-ended questions Motivational Interviewing (change talk) Appreciative Inquiry (what’s working/resilient) Positive Psychology (build on strengths) Behavioral Science & Human Development Mindfulness studies Wellbeing throughout the life spectrum Self-development & Self-care

Motivational Interviewing: A conversation about change “A collaborative, goal-oriented style of communication with a particular attention to the language of change … Designed to strengthen personal motivation for and commitment to a specific goal by eliciting and exploring the person’s own reasons for change within an atmosphere of acceptance and compassion.” (Miller & Rollnick: Motivational Interviewing: Helping people change)

(2) Components of MI A relational component focuses on empathy and the interpersonal ‘spirit‘ of MI. Draws on the presence of the practitioner – how you relate, listen & talk with the person you’re counseling in a caring, empathetic manner A technical component evokes and reinforces how patients talk about change. Counseling skills OARS (Open-ended, Affirm, Reflect, Summarize)

Stages of Change

Stages of Change Pre-Contemplation: I’m either unaware of a problem behavior or am unwilling or discouraged when it comes to changing it. “My doctor says I have to quit smoking, but I don’t see how that’s going to happen.” Contemplation: I’m aware of the problem, and am seriously considering doing something about it, but I’m ambivalent. “I want to quit smoking, but every time I try I gain weight…so I start up again.” Preparation: I want to make a change, and I have a plan to do it soon. “I’m going to quit smoking in a few months.” Action: I’m actively changing my behavior in concrete ways. “I’ve quit smoking and am wearing my nicotine patch.” Maintenance: I’m maintaining the behavior change as part of my life, and strategizing how to prevent relapse. “I’m still not smoking, and I’m figuring out new ways to stay relaxed so I don’t start up again.” (Motivational Interviewing, Nurse.com, CE 740)

4 Guiding Principles of MI Express empathy Develop discrepancy Roll with resistance Support self-efficacy

Resolving Ambivalence Motivational Interviewing is particularly effective during the Contemplation and Preparation stages, when people start to consider more seriously their reasons to change. It’s common and normal to encounter ambivalence about changing longtime habits – that’s the essential dilemma of change. It’s often hard, stressful, and uncomfortable. “I want to ______, but I don’t want to _______.” Roll with the resistance!

Readiness to change Ask the child how ready he/she is to make a change, on a scale of 1 to 10, with 0 being not interested, and 10 being very ready to try to change. 0 1 2 3 4 5 6 7 8 9 10

Change Talk – Listen for DARN Desire: Statements about preference for change, as in “I want to”…”I’d like to”…”I wish” Ability: Statements about capability, like “I can”…”I could”…”I might be able to” Reasons: Specific arguments for change – “I would probably feel better if I exercised…” or “I want to be able to play with my grandkids…” Need: Statements about feeling obliged to change, like “I ought to”…”I have to”…”I really should”

MI Tools: OARS & DARN Asking Open-ended questions Affirming and supporting Reflecting back the essence Summarizing periodically Change Talk Coaching Questions : Desire. “What do you want or hope for?” Ability. “What could you do?” Reasons. “What would be a benefit of doing that?” Need. “How important is this change to you?”

Asking Open-ended questions “What concerns do you have about your (diabetes)?” “What are you most worried about?” “What would it be like to have more energy?” “How have you been successful in the past?” “What have you tried before to make a change?“ “How would you like things to be different?” “ What are the good things about ___ and what are the bad things about it?” How this helps You will hear more of what matters to the student, and where she might be ready to change. The student is now more actively involved in the direction and outcome of the conversation. You will likely gain a good amount of knowledge about the student in a short time.

Affirming & supporting the student “You’re a strong person, to have coped with all of this.” “I appreciate that you took a big step in coming in here today.” “You handled yourself really well in that situation. “ “That’s a good suggestion.“ How this helps This builds rapport and trust, and encourages a student’s self-efficacy. It also reminds the student what strengths and effort he brings to the situation. We speak to their hope, resilience, and strength…not to their weaknesses.

Reflecting back the essence of what was said Student: “I can’t stand exercising because it’s so boring.” You: “You’ve tried different kinds of exercise and don’t like any of it.” Helpful phrases for reflective listening: “So you feel…” “It sounds like you…” “ You’re wondering if…” How this helps It shows the student that you acknowledge her thoughts and feelings, and that you’re listening well to what saying. Reflective statements are less likely to evoke resistance, as you’re using the student’s own words, and not trying to persuade or convince them with your own ideas. It serves to identify and reinforce the student’s own motivational statements.

Summarizing periodically “You told me that you’re worried you won’t be able to keep up with your friends if you don’t lose some weight. You watched your mother become diabetic and you don’t want to end up like that. However, eating helps you feel better after a hard day. What else?” “Let me see if I understand so far…” “Here is what I’ve heard. Tell me if I’ve missed anything. ..”  How this helps You periodically link together key thoughts that the student shared as a way of exploring his or her ambivalence to change. It allows the student to hear his or her own ‘change talk’ in a different way, or hear it for the first time. The goal of MI is to move through the exploration into a resolution of the ambivalence, and then guide the student to action steps he or she would be willing to take.

WAIT -- Pause Why Am I Talking

SMART Goals Specific: What you want to do, and how you’ll do it Measurable: How you’ll know when you’ve reached your goal Achievable: Your goal is possible for you to achieve. Realistic: The goal is appropriate for you, and you have the resources to make it happen. Time-sensitive: You set a target date when you plan to reach your goal. Goal: I will get more exercise by walking 3 times a week for 20 minutes over the next 2 months.

Other MI Tools Decisional Balance Change Rulers Assessing the pros & cons of making a change vs. keeping the status quo. Change Rulers On a scale of 0 to 10, with 0 as “Not at all,” 10 as “Extremely”: How motivated are you to make this change? How confident are you in your ability to make this change?

Self-Development ‘Walking the talk’ Contributes to ‘therapeutic presence’ & compassion Personal reflection Assessing our own challenges w/ wellbeing Self-care plan & practices Body – Mind – Spirit -- Relationships Self-awareness Reflective practices

Mindfulness: Being Present

“Is there anything you’d like to do for your health Let’s try it! “Is there anything you’d like to do for your health in the next week?” COACH: Reflective listening (WAIT) Ask open-ended questions No ‘fixing’ or giving advice Listen for ‘change talk’ – where there’s no resistance Explore possible obstacles Facilitate SMART goal CLIENT: What do you want to work on? Commit to (1) concrete, measurable goal for the next week What’s one thing you will commit to do today or tomorrow towards that goal? How confident are you that you’ll be able to do this goal?

Challenges for School Nurses Dynamic of student & parent – in different stages of change? Adapting MI language for children – how would you word questions? http://health.mo.gov/living/families/schoolh ealth/pdf/SchoolNurseInterventionstoPro moteHealthyWeight.pdf (Obesity) http://www.ncbi.nlm.nih.gov/pmc/articles/ PMC3262065/ (Exercise/Activity)

Contact Info Jan Booth, RN, BSN, NC-BC janetbooth15@gmail.com Motivational Interviewing Network of Trainers (MINT): www.motivationalinterviewing.org International Nurse Coach Association www.inursecoach.com