1. Motivational Interviewing: Promoting Adherence to Strengthen Transitions Kathleen K. Zarling, MS, RN, CNS Cardiovascular Clinical Nurse Specialist for High-risk CAD patients Mayo Clinic Presented to the Minnesota Chapter, NACNS October 26, 2012 Plymouth, MN

2. I Have No Disclosures Kathleen K. Zarling, MS, RN, ACNS

3. Objectives Upon completion of this presentation, the participant will be able to: 1. Define Motivational Interviewing 2. Describe the Four Main Principles of Motivational Interviewing 3. Discuss the Essential Elements of Motivational Interviewing: What it IS and what it IS NOT 4. Utilize individual Motivational Interviewing Techniques in role play exercises 5. Identify Barriers to Motivational Interviewing

4. Motivational Interviewing “ Motivational Interviewing (MI) is a directive, client- centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence.” (Rollnick & Miller, 1995, p. 325) MI is a person-centered counseling method for addressing the common problem of ambivalence about behavior change. (Miller, 2010)

5. Relational aspect Ambivalence is resolved through empathy and a spirit that instills capability Technical aspect Ambivalence is resolved through the selective reinforcement of a client’s thoughts and commitment for change Essential Elements of Motivational Interviewing (MI):

6. ♥ Ambivalence refers to feeling two ways about a behavior ♥ Getting stuck in ambivalence is common and should be expected I know I should exercise more, But I just don’t have the time Ambivalence is Normal in Making Lifestyle Change

7. Motivational Interviewing: Technical Definition MI is a collaborative goal-oriented method of communication with particular attention to the language of change. It is intended to strengthen personal motivation for and commitment to a target behavior change by eliciting and exploring an individual’s own arguments for change. (Miller, 2010)

8. Principles of Motivational Interviewing ♥ To express empathy ♥ Support self-efficacy ♥ Develop discrepancy ♥ Roll with resistance These four main principles must be maintained to have a therapeutic interaction with patients. (Levensky, Forcehimes, O’Donohue, & Beitz, 2007; Rolfe, 2004; Miller, Zweben, DiClemente, & Rychtarik, 1992)

9. New Guiding Principles of Motivational Interviewing R= To resist the righting reflex U= To understand & explore the patient’s own motivations L= To listen with empathy E= To empower the patient (Rollnick, Miller, Butler, 2008)

10. What Motivational Interviewing (MI) IS NOT: MI is not: ♥ Stages of change Decisional balance A Technique Just patient centered or client centered counseling Not a form of Cognitive Behavioral Therapy (CBT)

11. Can it be MI without Engaging? NO The communication style and spirit involve empathic, person-centered listening Essential Elements of Motivational Interviewing (MI):

12. Can it be MI without Guiding? NO There is a particular identified target of change that is the topic of conversation Essential Elements of Motivational Interviewing (MI):

13. Can it be MI without Evoking? NO The interviewer is evoking the person’s own motivation for change Selective eliciting, selective responding Essential Elements of Motivational Interviewing (MI):

14. Can it be MI without EngagingNo GuidingNo EvokingNo PlanningYes Establishing a change plan Consolidating a commitment Essential Elements of Motivational Interviewing (MI):

15. The Spirit of Motivational Interviewing “The Dance” ♥ COLLABORATION~~NOT CONFRONTATION ♥ EVOCATION~~NOT JUST EDUCATION/ADVICE ♥ AUTONOMY~~NOT AUTHORITY Carefully eliciting the values, assumptions, fears, expectations, and hopes of the person.

16. Enhancing Patient Connectedness Through the Nurse-Patient Relationship ♥ “Utilizing the theoretical framework of the theory of modeling and role-modeling (MRM), patient connectedness is a relationship that begins at the moment of initial contact between nurse and client with recognition that the relationship itself is integral to the nurse’s ability to model the client’s world.” (Erickson et al., 2006) ♥ “The initial relationship continues to grow and develop into a bond between the nurse and the patient. The patient is the central focus of the nurse’s care & all interactions and interventions are based from the patient’s perspective.” (Mitchell, 2007)

17. Enhancing Patient Connectedness Through the Nurse-Patient Relationship ♥ One of the greatest benefits of nurse-patient connectedness is the establishment of trust between the nurse and the patient (Erickson, 2006) ♥ Patients tend to better trust nurses who establish a relationship with them. (McCabe, 2004) ♥ An established relationship between the nurse and patient will, many times, lead to a feeling of safety allowing the patient to share more freely and openly with his/her nurse, than with loved ones. ( Anderson, 2007)

18. Assisting Patients to Achieve Healthy Behavior Change #1. Accept that changing is difficult & each individual must develop their own, individual way of changing (What works for one individual, does not always work for another.) #2. Understand that changing is a process, not a single decision or act (Change made over time can become a healthy habit individuals don’t want to lose.) #3. Make changes in small increments, as little adjustments add up to big benefits (Don’t try to change everything at once!)

19. Achieving Healthy Behavior Change #4. Learn about & understand the stages of change Stage I: “I don’t need to change!” (Pre-contemplation) Stage II: “Sure, I’ll change, but not right now. (Contemplation) Stage III: “I want to change, but I’m not sure how to start” (Preparation) Stage IV: “Let’s do it!” (Action) Stage V: “Now, if I can just keep at it!” (Maintenance)

20. Prochaska’s & DiClemente’s Stages of Change Prochaska, J.O., & DiClemente, C.C. (1982). Transtheoretical therapy: Toward a more integrative model of change. Psychotherapy: Theory, Research, & Practice, 19, 276-288.

21. Motivational Interviewing Traffic Light Resistance Ambivalence Change Talk Stop Elicit/Explore Move Forward (Dart, Michelle A. (2011). Motivational Interviewing in nursing practice: Empowering the patient.)

22. Methods Used in Motivational Interviewing: ♥ OARS ♥ DARN-CATS! ♥ CHANGE TALK

23. OARS – ♥ Open ended questions ♥ Affirmations ♥ Reflective listening ♥ Summary statements “OARS”

24. “DARN-CATS!”….Elicits Change Talk DARN: ♥ Desire “ What do you want, like, wish, hope, etc.? ” ♥ Ability “ What is possible? What can or could you do? What are you able to do? ” ♥ Reasons “ Why would you make this change? What would be some specific benefits? What risks would you like to decrease? ” ♥ Need “ How important is this change? How much do you need to do it? ”

25. “DARN-CATS!”….Elicits Change Talk CATS: ♥ Commitment ♥ Activation ♥Taking Steps

26. CHANGE TALK Involves The Client’s: ♥ Desire to Change ♥ Ability to Change ♥ Reason to Change ♥ Need to Change

27. The Coaching Conversation Skills involved in the Mayo Clinic’s Wellness Coaching Model: ♥ Engaging the patient ♥ Exploring values, strengths, & desires ♥ Facilitating a vision with a client ♥ Assessment & enhancing motivation ♥ Responding to resistance ♥ Recognizing & responding to change talk ♥ Utilizing E-P-E (Elicit-Provide-Elicit) when providing information/advice ♥ Using empathic redirection communication strategies

28. BRIEF INTERVENTION E-P-E Elicit- Provide- Elicit Elicit what they know Provide information Elicit what they think or feel about it

29. Barriers to Effective Motivational Interviewing

30. Barriers to Effective Motivational Interviewing

31. Collaborative Goal-Setting - Challenges and Opportunities ♥ MI rests on a cooperative & collaborative partnership between the patient & clinician ♥ MI addresses a specific situation where patient change is needed ♥ MI utilizes an active & equal collaboration, conversation & joint decision-making between the client and patient (Rollnick, Miller, and Butler, 2008)

32. Role Play on Developing Ambivalence & Discrepancy to Promote Behavior Change ♥ Work in a group of three ♥ Each individual take 5 minutes to role-play with one other individual, with the third individual being the observer, sharing observations ♥ Please make sure each of you has time to be the interviewer

33. Cardiac Rehabilitation can be productive for EVERYONE! Promoting Adherence & Strengthening Transitions Creates Quality Care

34. THANK YOU! zarling.kathleen@mayo.edu