... in which those who disagree can do so with honor and respect for other people's opinions and an appreciation of our shared humanity.â Marianne Williamson.
Kathlynn Northrup-Snyder PhD, RN Yupawan Thongtananumun PhD, RN APHA 2010, Denver, Co.
No slide in this presentation can be copied or changed without author permission
Presenter Disclosures Kathlynn Northrup-Snyder (1)
The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months:
Dr. Northrup-Snyder is the owner of Community Health Concepts, a company that may have a commercial interest in the results of this research. This potential conflict of interest has been reviewed and managed by OHSU.
“Is not one in which we all agree. It is one in which those who disagree can do so with honor and respect for other people’s opinions and an appreciation of our shared humanity.” Marianne Williamson (emphasis presenter’s)
Cultural
mis-understanding can happen when nurses make assumptions based upon their own perceptions or fail to gather enough information from the client. To become global citizens nurses must • Be aware of personal beliefs & practices • Practice egalitarianism and collaboration as
demonstrated in genuine concern for the welfare of all. • Develop accurate understanding (empathy) of others Crigger, Brannigan, & Baird, 2006- based upon Nussbaum’s 1997 work
Sensitize
nurses to their own culturally established perspectives on health care. Explore personal attitudes of persistent personal views & any romanticizing of other cultures. Raise nurses awareness about their underlying values & assumptions in the health care system, their practices, & their education. Crigger, Brannigan, & Baird, 2006- based upon Nussbaum’s 1997 work
Expose
nurses to other cultures as an underpinning to teach individuals to think for themselves (even individual connections are good).
Integrate
into curriculum citizenship & social justice themes that include global care.
Crigger, Brannigan, & Baird, 2006- based upon Nussbaum’s 1997 work
Motivational interviewing is a collaborative, goaloriented method of communication with particular attention to the language of change. It is designed to strengthen an individual’s motivation for & movement toward a specific goal by eliciting & exploring the person’s own arguments for change. (Miller, 2010) Developed by Bill Miller and Steve Rollnick in the 1980’s for work in addictions
Assumptions of MI MI is a particular kind of conversation about change • IE counseling, therapy, consultation, a method of communication • MI is collaborative • IE person-centered, partnership, honors autonomy, not expert-recipient • MI is evocative, seeks to call forth the person’s own motivation and commitment
•
(Miller, 2010)
• Compassion is imbued throughout.
Through Improved Cultural Understanding • Check Assumptions • Gather Enough Information Creating a World Citizen • Practice Equality, Collaboration & Genuinness • Awareness of Beliefs and Practice • Accurate Understanding
Social Justice
Key Engagement Skills Linked to a Goal OARS
Open Ended questions Affirmations Reflection Summary
DARN-CATs
Desire (want, wish, like) Ability (can/could, able) Reasons (Benefits/risks, why) Need (Importance)
Changing Context Commitment (I will) Activation (I’ve started) Taking Steps
Retrospective
analysis of 5 separate terms of a 10 week Health Promotion course offered online or in face to face sessions.
6
hours of Motivational Interview training with 1 audio taped client/coach interview
Motivational
Interview Reflection Papers Week 10 wrap-up reflection & “ah ha”
Demographics
166 RNs returning for BS degree • Years of Practice – 34% = 20 – 13% unknown • Age -- 25% = 20’s -- 31% = 30’s -- 26% = 40’s -- 14% = 50’s -- 4% = unknown
• Practice type – 79% Acute care – 8% Community – 6% Adult care – 2% Office, misc. – 5% unknown •Gender (89% female) •Race
(83% White)
Shifts in communication patterns & thinking related to: •Respect of client: Self-knowledge Readiness Confidence Autonomy Authority As an individual As a teacher
•Non-judgment •Role of Guide •Offering “grace” •RN focused goals for patient increases mis-understanding •Health Care Providers can create client resistance
Respect as an individual-
“Trying to make a lifestyle change, employing if for sometime, and then falling off the wagon is extremely difficult and is undoubtedly shameful for our pts. Readjusting their approach and trying again deserves applause and encouragement. My ah ha moment will make me be a better cheerleader for these pts that come in to our ERs or are admitted to the floor d/t the same problem (diabetes, smoking, wt, diet). I will treat them compassionately, listen empathetically and help them to re-evaluate a plan that will work, and most importantly, I will applaud them for sharing their stories and having the drive to try again…” HPOFall064
Self-Knowledge- “It is very difficult, until it is experienced, to believe that a client/patient can come up with their own solutions to their problems; however, this did indeed happen.” HPINTSpr061
Readiness- “I think it is so easy to say, “maybe you could”, or “have you ever tried” in an effort to relate, but I think that it usually leaves an individual feeling like a failure.” HPOSpr071
Autonomy- “You cannot force anyone to do anything they don’t want, and the more you try to, the more they will resist. The conversation should also go at the pace that the client is most comfortable. You always want them to think they have control over their own actions, because they really do.” HPOFall058
Guiding-
“By utilizing the motivational interviewing I can direct the “client” in a specific direction but they get to set the guidelines, make the rules, and set up a plan for change. It is a lot easier than I had originally anticipated. The interviewer is able to basically sit back and relax and let the “client” do all the work.” HPOFall05
Grace- “There HPOFall0514 HCP
is no such thing as failure!”
creates resistance- “I also found that a lot of the words we used did not work and put change off.” HPOFall058
Skilled Communication
Listening Skills
•Importance of Communication •MI skills empower the client •Practice skills for success •Beyond Therapeutic Communication •Right words and inflections •OARS for assessing •Correctly targeting the behavior •Targeting the message
•Become a better listener •Silence is golden •Hear the story •Hearing vs fixing •Active listening
OARS
for assessment- “Using affirmations,
open ended questions, and reflection allowed the client to identify the problem, look at the past issues and what worked and what didn’t. Using MI helped to identify the related health issues and benefits of weight loss. I watched [client] go from the contemplation stage to the preparation stage.” HPOFall0612
Silence is golden- “Another valuable experience I had was when I played both coach and client. I really learned that silence, although maybe uncomfortable, is a beautiful time for reflection. As the coach, I asked my client the ‘where does this leave you’ question, and was met with a period of silence. Contrarily, in the next round when I was in the role of client and was asked that question, it took genuine thought for me to formulate an answer. I realized that reflection is a process and it may take thought, time, and a period of invaluable silence.”
Becoming a better listener- “I think that we all agree that ‘being a good listener’ is extremely difficult.” HPOFall0514
Active listener- “I have always thought of myself as more of a listener than a talker, but realized there is a difference between just listening and actively listening. Having to perform frequent reflections increased my active listening and made me realize that in the past I have not been the best active listener.” HPOFAll057
Hearing the Story- “I wanted to know if she had attempted to quit before and if so, what was it that she felt contributed to relapse. I found that she had attempted to quit three times and relapsed due to job loss, death of a close friend, and then the passing of her grandfather.” HPOFall061
Practice Fit of MI• A good fit –
“I have been modifying my care in ways that incorporate use of MI techniques into every bedside encounter. Results have already proved positive….Careful questions at the correct time have left my patients with ‘food for thought’ so to speak :) and the next time I come into the room I find a lot of them tend to pick up where we left off without me starting the conversation..” HPOFall059 • A difficult fit for acute care • Confidence of the RN to use MI
Benefits of MI Skill
• Improved Patient Satisfaction • Improved RN satisfaction • Improved Supervisory satisfaction
Ingrained beliefs- recognition and shifts • Vulnerability of the client • Value in planting seeds • RN role of the expert • Compliance is an option • Health care or educational taught beliefs • New perspectives overall • Judgments System created non-compliance Personal judgment about patient follow-through Recognition of judgmental language
Planting seeds- “With a positive or affirming position, a health coach can encourage the cultivation of behavior changes in others, planting seeds of change one encounter at a time.” HPINTFall061
RN Role of Expert- “I realized how torn I am between feeling obligated to give advice and provide education verses needing to be more of an active listener.” HPOFall051
Health care- “…the value is evident when I use these health promotion tools in practice. The problem I am one against many who have not taken this class or done research in regards to influencing behavior change in clients.” HPOSpr0712
Non-compliance- “I'm no longer going to say that my patients are noncompliant. It just may be that they are not ready to make a change yet. As nurses and doctors we get so caught up in thinking that all we need to do is tell our patient what they need to do and when they don't, we say its their fault they are noncompliant. Instead we need to take it further and find out the whys.” HPOFall0530
Personal judgment- “I will always wonder 'why doesn't this person change', 'what will it take', 'why can't they see how this affects them', 'how can I help' and many others. My tentative answer to all of this is just keep practicing and keep trying. Ask others for input and keep an open mind.” HPOSpr0616
Personalizing Being
the encounter
Present Checking for accurate understanding Outcome when not “pushing” the client
Personalizing the encounter- “I have found that open ended questions are a great way to begin discharge teaching. For example, once a patient is past the initial post-operative period and is beginning to look ahead to discharge a simple question like “What concerns you the most right now?” can give the patient the opportunity to discuss a wide array of topics that will affect their recovery after they leave.” HPOFall0517
Outcome when not “pushing” the client- “because of the power of the questions to elicit new thoughts and ideas. … I found [in the client role] I wanted her to “get it” and understand my point of view. There was a spirit of camaraderie and support. I contrast this experience with my visit to my GP a few days ago, where I felt bombarded with his agenda…, and ended up in no way feeling understood.” HPINTSpr061
Belief in a spirit of openness- approaching with MI Spirit
Autonomy of choice- pt choice to change via
exploring readiness/importance & personalizing plans
Promoting Change• • • •
Control of personal life- effectiveness of personal plans Pt doesn’t need advice Elicit solutions from pt Beyond giving information
Elicit solutions- “During frequent interactions with [older immigrants with chronic illness] I learned a lot about their health conditions by just listening to what they had to say. I used reflection, affirmation, summarizing, and, of course, advice giving. I knew that they have heard my information many times before, but I felt that it was my professional duty to "educate" them again and again. If I [had MI then], I would've tried to elicit solutions from the clients themselves.” HPOFall0532
“it makes sense to promote change and health when it comes from within ourselves. It helps create self awareness, self esteem and when the client leaves the interview they could have a multitude of feeling or thoughts. Hopefully one of those feelings won't be feeling bad about themselves.” HPOFall0624
The
philosophy of Motivational Interviewing & the use of these skills • Shifts focus: rather than “blaming” the client, the
health care professional becomes aware of the many variables and their role in facilitating change…
• May effectively facilitate: Movement from Acquired
Social Consciousness toward Expanded Social Consciousness…
(A model of social consciousness, Giddings, 2005)
Crigger, N. J., Brannigan, M. & Baird, M. (2006). Compassionate nursing professionals as good citizens of the world. Advances in Nursing Science, 29, 15-26. Giddings, L. S. (2005). A theoretical model of social consciousness. Advances in Nursing Science, 28, 224-239. Miller, W. Looking forward to MI-3: A work in progress. Motivational Interviewing Network of Trainers Forum 2010 (Oct. 7, 2010). Nussbaum, M. C. (1997). Cultivating Humanity. London: Harvard University Press. Williamson, M. (nd). Miracle Cards (revised ed).
