Lighting the fire in Diabetes Self Management Education

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Edward L. Lee MBA RN CDE VP: Viewpointe Inc. International Diabetes Behavioral and Education Center, Philippines li_yan_tao@comcast.net 4/18/12

Motivational Interviewing (MI) Interviewing

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What is it? Why do we need It? How is it used? Does it work?

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DSME with MI
Education is not the filling of a pail but the lighting of a fire.
by William Butler Yeats

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Ones mind, once stretched by an idea will never regain its original dimension.

Oliver Wendell Holmes

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Current medical Model of diabetes education

Persuade or convince a patient to change Extrinsic motivation Decreases the patient's autonomy Often increases a patient's resistance Diabetes Topic/Content-oriented Believes that logic, fear and pressure will prevail Ends in frustration for both 4/18/12 Not behavior change oriented

Current Model (continued)

Direct questioning Persuasion Health information giving Advice-giving All have been the workhorse techniques of the current system. However, these strategies have proven to be of limited effectiveness in the management of chronic illnesses and a source of frustration to patients and clinicians alike.

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The mental process, function, or instinct that produces and sustains incentive or drive in human and animal behavior. Components

Motivation

1. Willing: degree of discrepancy between current behavior and future values 2. Able: confidence for change 3. Ready: setting priorities

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Counter-Motivation
1.
. . . .

Characteristics

Resistance Hopelessness Low self-efficacy Chronic Ambivalence Interrupting Ignoring Arguing Denying Changing subject Talking off subject Daydreaming Manipulation
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2.
. . . . . . . .

Signs

Strategies That Dont Work

Urging more willpower kaya mo iyan! Kulang ka lang sa motivation Maging seryoso ka naman diyan sa dyabetes mo!. Threatening bad outcomes Gusto mo bang maagang mamatay? Ikaw rin, ang bata pa ng magandang asawa mo? The gift of advice bakit hindi ka mag member na lang ng Makati fitness center Eat a proper diet(whatever that is?) As your doctor, ito ang advise ko sayo
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AADE Health Care Outcomes continuum

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Motivational Interviewing

Introduced by Drs. William Miller and Stephen Rollnick in early 1990s (drug and alcohol addiction). Revised in 2008 with Christopher Butler for health care.

New definition (2008) A skillful clinical style for eliciting from patients their own motivation for making changes in the interest of their health.

Rollnick, Miller and Butler. Motivational Interviewing in Health Care: Helping 4/18/12 Patients Change Behavior, 2007.

MI is not New

addictive behaviors HIV risk reduction eating disorders criminal justice case management fruit and vegetable intake exercise major psychiatric disorders.
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Theoretical Underpinnings of MI

Its patient-centered approach and focuses on empathy and strong reflective listening skills. theoretical influences include Bem's Self-Perception Theory, Janis and Mann's Decisional Balance Theory, Prochaskas Transtheoretical model, Carl Rogers and adult education principles. Hettema et al studies shows that MIs allowed more Change Talk and less Resistant Talk.

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How is MI used?

is a patient-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence and help improve selfefficacy.
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Trigger for a healthy behavior change

Behavior change seems to arise when person connects with intrinsic value, something important and something cherished. This seems to happen under an accepting and empowering atmosphere.
*William Miller and Stephen Rollnick; Preparing People for Change

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Patients Path to Long term self-care is interspersed with relapses

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In Plain English,

MI is an anti-ambivalence counseling skill

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MI cannot be learned in 15 minutes... Or today

The following Theoretical Models are constantly and dynamically utilized during each counseling. There is no strict order that they should be used because the interview is Patient-Centered.
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Key Elements of MI
*express empathy 2. *roll with resistance 3. develop discrepancy 4. support self-efficacy * The first two elements pertain to the practitioner-patient relationship.
1.

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The Spirit of mi
1.

2.

3.

collaborate and empower the patient (Let's put our heads together and review the options.) support and respect patient autonomy and problem-solving capability. develop intrinsic motivation by eliciting change talk from the patient regarding the target behavior and behavior change.

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Reflective Listening
1. Allows you to have a complete grasp of the message without being distracted by many emotionally loaded words 2. Normally begins with Phrases such as: So it sounds like In other words, You mean, It looks like It seems that 3. A key communication skill is to signal in your voice an uncertainty rather than a judgment signal.

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Adult learning

Autonomous and SelfDirected New knowledge is related to life experience & is relevant and practical Goal-oriented Respect and dont like being judged

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Health beliefs model

Based on the understanding that a person will take a health-related action if patient perceives the following in relation to his/her chronic illness: Perceived Susceptibility Perceived Severity Perceived Benefits Perceived Barriers can be overcome Perceived Self-Efficacy

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How do you speak using mi?

Open ended questions Affirmation Reflective Listening Summarize

O.A.R.S. approach
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A four-step patient empowerment model

Explore the problem or issue Clarify feeling and meaning Develop a goal and start a plan Commit to action

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How does a successful mi session looks like?

The patient is doing most of the talking. The patient is discussing a specific behavioral target The practitioner is focusing on problem recognition, a teasing out of ambivalence regarding change, and the what, when, and how of any change that the patient might be ready for. Helping the patient work through normal ambivalence around change is also a key focus.

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How does your patient looks like when you package dsme with mi?

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Explore the Problem or Issue

Sample Question:
What is hardest for you? What concerns you about diabetes? Encourage them to tell their story, if you sense ambivalence, have them tell you about both sides. As you listen, try to form statements out of what they say. Emphasize important points when you summarize.

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Clarify Feeling and Meaning

Sounds like you feel (angry, sad, frustrated) because you___________________________.

Summarize while building motivation: Ang dinig ko sa mga sinabi mo, ay sa ngayon alam mo na ang hindi pag-check ng blood sugar mo ay may kasamang problema at napapansin mo na rin hindi maganda ang pakiramdam mo kung mataas ang blood sugar mo. At sa ngayon, gusto mo nang matuto kung papaano mo malulunasan ito.

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Develop a Goal and Start a Plan.

"Where would you like to be regarding____ (3 months, 1 year) from now? What are your options? What are your barriers? Who could help you?" Offer advice only when requested, and offer it as things you have seen other similar people do. Offer as a cluster of ideas with a preface... "I don't know if any of these ideas would work for you, but I worked with some other people with diabetes and they have...

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Commit to Action

"What are you going to do? When? How will you know you've succeeded? How confident are you? Use action plan-specific goal and plan for the next week or two at most. Explore confidence and readiness. If not ready, you can say "This is a big decision. If you're not ready yet, I don't think you should make a commitment. You think about it and we'll talk again next visit."
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More Sample Questions

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How to build Rapport?

Mirror their body language. Mimic their tonality During the conversation, breathe like they breathe Match their rate of speech Repeat and approve or acknowledge Assume you already have rapport

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Additional subtopics that you will need to learn in a formal mi training

Understanding Ambivalence Decisional balance tool MI reflection breaks use of conditional language aka WIGGLE WORDS Agenda-setting: opening the door Menu of diabetes options tool for patient confidence ruler

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1. Minimum of 2-3 days initial competency-based training a. empathy/effective Listening b. MI spirit dimensions c. asking permission before providing advice or info d. affirmations to acknowledge strengths or effort e. OARS approach f. ECDC approach g. Build Rapport h. Builds Confidence i. Explore Importance k. Prochaskas Stages of Change
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Recommended mi training for current and future diabetes educators

Planned Future Venue for mi training Subic Bay Freeport

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