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” 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 change  Try to increase confidence (self-efficacy)  (higher confidence = higher chance of change  Keep the patient in charge of the process, solutions need to come from them  Decision 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 