Applying Motivational Interviewing Techniques

[Scott Crespy]

On July 13, 2004 the Clinical Education Department at Kaleida Health video-conferenced a wonderful 1-hour Nursing Grand Round training entitled "'What?! Me Change' Helping Your Patient toward a Healthier Lifestyle; i.e. Smoking Cessation" to the five hospitals in their network (over 100 nurses attended). In addition to sharing past and present data regarding their smoking cessation processes of care, the major focus was on teaching many of the Motivational Interviewing techniques that have been shared in the Smoking Cessation Collaborative (See Smoking Cessation Library: Motivational Interviewing Department (http://jeny.ipro.org/showthread.php?t=60) above). As a memory aid for their staff, they created "Lifestyle Change" Hang Tags (see below).

http://jeny.ipro.org/files/crespy/80kaleidatagfront.jpg (http://jeny.ipro.org/attachment.php?attachmentid=274&stc=1)http://jeny.ipro.org/files/crespy/80kaleidatagback.jpg "Lifestyle Change" Hang Tags. (http://jeny.ipro.org/attachment.php?attachmentid=274&stc=1)

The front of the tag lists 10 important tips for conducting effective brief counseling interventions with hospital patients who smoke. It includes suggestions such as: Offer a menu of options; Explore importance and confidence; Dance, don't Wrestle; and Close on good terms. Presenters mentioned that they received very positive feedback and that the attendees were genuinely very interested in learning more.

This training served as a fantastic way to expose front-line staff to Motivational Interviewing techniques and it is hoped that it will generate more interest and begin to enhance the smoking cessation counseling conducted in their hospitals.

Hospital personnel all across New York State have begun to review and integrate Motivational Interviewing techniques into their day-to-day work. Please consider sharing your experiences in teaching and/or applying these techniques in your work. Thanks.

Scott Crespy, Ph.D.
Smoking Cessation Project Manager, IPRO

[Mary Brown]

Hello Everyone,
It has been 2 months since our training to professional staff on how to implement QUICK yet EFFECTIVE motivational strategies for patients regarding lifestyle changes. The feedback has been positive. Our next step will be to reinforce the training by presenting a brief review at the nurse managers' meetings throughout our hospital system.
The biggest challenge so far has been establishing a designated area on each nursing unit to house the booklets and also creating a process for replenishing the supply. We plan to do some creative problem-solving on this with the nurse managers.
This continues to be an exciting initiative for us, as it directly benefits our patients. We are very fortunate to have the resources of the IPRO team so readily available.
Mary Brown

[Scott Crespy]

Hi Mary-

Thanks for the update. It may be too early to know, but have you heard back from any of the staff that attended the Nursing Grand Rounds training about whether they have tried to use the Lifestyle Change/Motivational Interviewing techniques yet? Have you been able to get the "hangtags" out to staff?

Anyone who is reading this message that has a process for supplying/replenishing units with smoking cessation literature can feel free to share their experiences on this message board.

Are there any other hospitals in the collaborative trying to incorporate Motivational Interviewing in their work with patients?

-Scott

[Barbara Goodwin]

Cayuga Medical Center at Ithaca is interested in learning more about Motivational Interviewing Techniques.

[nampahc]

Interested in applying MI and training others to use it.

R Chapman

[Linda Mazzella]

Saint Francis Hospital is interested in training others and forming support systems for cessation counselors.

[jackie minick]

I work in the Quality Management Department and my interest is in establishing a program here at our hospital and get others trained in motivational interviewing.

[Scott Crespy]

Hi Barbara, Jackie, Linda, and Robert. Thank you for posting on this discussion board and for sharing your interest in Motivational Interviewing. I am noticing a growing number of hospitals that are expressing an interest in using Motivational Interviewing techniques and I am very interested in finding ways that we can work together to further develop this topic in the hospital setting.

I would be very interested in hearing your thoughts about this. In a recent discussion with Dr. Robert Chapman, the idea of presenting a "Grand Rounds" on an upcoming conference call or newsletter came up, which would highlight the use of MI with a patient. What do you think? Do any of you have any other suggestions?

Scott Crespy

[nampahc]

For additional resources on MI, please visit my web page and scroll down to the section on Motivational Interviewing - http://www.robertchapman.net

For a simple power point that provides an overview on MI visit: http://www.lasalle.edu/~chapman/mi.ppt

Robert J. Chapman, PhD

[Scott Crespy]

Thanks for the great resource Robert. I wonder if any of the folks in hospitals have thought about how they would like to begin to apply some of the Motivational Interviewing (MI) techniques? Where would people like to take this next? Also, I know there are people in other hospitals that are interested in MI as well, please post onto this board and let us know you are out there. Thanks.

Scott Crespy

[elaine diederich]

Hi Scott,

The staff is gradually becoming more comfortable with the motivational interviewing techniques and the hang tags are being distributed through the nurse managers.

-Mary Brown

[Linda Horton]

I have a question about the concept of patient centeredness. Patients often feel that they loose control when they are in a health care setting and they are not part of the decision making process. This can be a time when they may feel most vulnerable and out of control. How important is it to give patients a sense of control over the process? What is the impact of this on their success with quiting? We tend to teach some standard ideas and strategies but this may not be meeting the patient's specific challenges and expectations. I would be interested to hear from Chris Dunn and all others on the concept a truly patient centered approach and how this can impact successes/outcomes. I would also be interested to hear from others who have implemented a patient centered approach to their programs.

Linda Horton (570) 348-7015

[Scott Crespy]

Hi Linda,

You pose an excellent question and I would love to hear what others have to say. It would seem that Motivational Interviewing has some very good techniques for helping patients feel more "in-control," while they are hospitalized. The idea of offering patients "options" throughout the smoking cessation discussion(s) come to mind. It would seem that the more patients are actively involved in making choices and decisions about their smoking (or any other lifestyle change), that they might feel more of a sense of control in an already very out-of-control (being hospitalized) situation.

It would seem that the more that healthcare providers could facilitate patients taking a greater degree of "ownership" and a more active role in their recovery the better. It is after all the patient who will need to deal with these issues after they are discharged from the hospital. What do you think?

Scott Crespy, PhD
IPRO Smoking Cessation Project Manager

[Dr Stimler]

Dear Linda,


You have asked a very important question. The sense of being out of control for some patients can interact in a negative way with the valuable education they might be receiving. I believe this is because "passive" learning, which is inevitable to some extent in a hospital setting but never as good as "active" learning [where there is more participation by the patient], can be further impaired by a sense of loss of control. Patients can become overwhelmed by even modest amounts of new material if they feel that they cannot control the environment around them.

A pervasive sense of loss of control also characterizes a primary difference between the hospital and home environments, and the gaining back of "control" shortly after returning home commonly coincides with relapse behavior (going back to smoking, etc.). In my opinion, one reason for this is that the negative experience of loss of control actually weakens other positive associations with the cessation experience in the hospital.

A constructive approach to this difficulty is essential, but clearly difficult, since it requires an institution-wide cultural change - firstly, to recognize the importance of this issue. One interesting tool that has been used is the "patient version" of a clinical pathway - that is, providing the patient with a laypersons version of the expected day-by-day activities for their admitting diagnosis. For those hospitals already using clinical pathways, creating "patient" versions should not be too difficult, although understanding their importance may be the harder goal to achieve. Giving patients a chance to anticipate, understand, and respond to ongoing clinical interventions can empower them and ameliorate fear and uncertainty. I think patients can benefit from this approach in other ways as well - for example indicating at the time of admission that they will be receiving cessation counseling and may be offered NRT, etc., even before any of the interventions are begun. This may act in a subtle way to soften patient resistance since the suprise factor is removed and patients may actually subconsciously work towards adaptation to the expected change.

Let me know what you think.

Dr. Stimler

[nampahc]

Participants in this discussion may find this online text regarding Motivational Interviewing (MI) to be of interest. NOTE: This is an entire book available online so you will not be reading this is one sitting :) Visit http://www.health.org/govpubs/BKD342/

Robert Chapman

[Linda Horton]

Thank you Scott and Dr. Stimler for your thoughts on the question of patient centeredness and how this concept can play a role in the long-term success of a smoking cessation program. Using this email thread process is a great way to share thoughts and ideas. Thank you for making it available to us.



I agree with your comments that allowing the patient choice and bringing them into the process (i.e. patient level care paths) are all good ideas to help effect this change and can be easy to do. It will be a start that will help move the program toward patient centeredness. Taking it to the next level is more of a challenge and a huge culture change. I think it will require us to look at how we can easily bring flexibility to standardized processes. The idea of motivational interviewing really drives this point home for me. Asking the patient about their readiness to quit smoking and what they are willing to commit to right from the start and/or what might work for them.



We use so many teaching books, hand outs and brochures that give good information, but could be looked at by patients with thoughts of "that will not work for me". So how do we get past the "passive learning" of smoking is not healthy and to the point of working with patients to develop a specific program (built on their needs with them in control) to help them stop smoking that they can continue over their lifetime. Is it possible to engage a patient/family while in the acute care setting knowing that may be the only time we have them? Can we use motivational techniques to build a customized program with the patient/family? After all the patient is the one who needs to quit smoking. Thoughts.....



Linda Horton

570-348-7015

[cdunn]

Hi Everybody: I just logged on to JENY for the first time today at Scott Crespy's invitation (thanks, Scott!) and am dazzled by the cornucopia of ideas. The first question these readings got me asking myself was, "How patient-centered do I have to be when talking with my patients to maxize the chances that they will change after I talk with them? I might as well confess that I don't always hang out in the clinical zone that Bill Miller (founder of motivational interviewing) calls "equipoise", where the clinician is truly detached from the outcome and seeks only to help the patient explore change and figure out what they want to do. I'm usually not detached, because I usually want smokers to quit smoking. And heavy drinkers to quit/cut down on their drinking. And sedentary people with diabetes to exercise. And and and.

But when an intervention goes well, it's usually because I'm the less Buddha-like zone of wanting change but basking in (ephemeral) acceptance that not all patients are going to change right away. When I am in that zone, my brief interventions go much better, probably because I'm not broadcasting muffled disapproval or frustration. And this seems to help patients to open up more and to explore new territory without exerting lots of energy to deflect suggestions coming prematurely from me to take immediate action.

As for patients being in control, I must say that it works better for me to first get some sort of agreement with patients to discuss things that they'd rather not discuss (such as lifestyle change). I think that's why the agenda setting methods (e.g., "I'd like to understand more about your smoking, but you must have other things in mind as well...) are so important. Grant Corbett recently wrote on another listserve that he would like to add another "A" to the 4 or 5 "A"s of smoking cessation counseling: Agenda setting. I believe (I'm just sharing a belief here, not claimed knowledge) that we are better off erring in the direction of giving patients more control by taking time to get buy-in to an agenda, offering them a menu of options rather than a single one, etc. But I think it's also dangerous to become a "motivational interview true believer" by assuming that this is the only legitimate approach for working with patients, because that would be silly. I don't think we yet know how much "patient-centeredness" translates to the best outcomes with this or that patient. For now, it seems that our best bet is to be a patient-centered as our own personalities and time limitations permit, and to keep our third eyes focused on signs of resistance. I think we're left with relying on resistance to guide our interventions. If resistance is seen as a signal to switch strategies, then maybe it's a good thing that there's lots of it around these days?

[Scott Crespy]

I am really enjoying this discussion. I noticed that the American Medical Student Association (AMSA) has already incorporated the idea of "Agenda Setting" as their first "A" in an excellent document that they developed called: "Health Dialogues - Tobacco Use: A Tool to Help You and Your Patients Change Unhealthy Behaviors." There is a link to this document in our Using the Public Health Services Guidelines (PHS) for Smoking Cessation (http://jeny.ipro.org/showthread.php?t=219) thread. The AMSA also encourages the use of three Behavioral Change Models: Stages of Change, Motivational Interviewing, and Health Belief Model. Perhaps they would be interested in working with us in our efforts to better integrate Motivational Interviewing with aspects of the Public Health Services Clinical Guidelines (e.g., 5As, 5Rs). What do you think? I would love your reactions to their Health Dialogues document. Thanks.

Scott Crespy

[Scott Crespy]

Dear Colleagues,

Over the course of the last year, our collaborative has worked towards incorporating Motivational Interviewing techniques into hospital-based inpatient smoking cessation counseling. Recently, we have begun to highlight various ways that Motivational Interviewing (MI) might fit into the framework of the 5As and 5Rs (i.e., Ask, Advise, Assess, Assist, Arrange; Relevance, Risks, Rewards, Roadblocks, Repetition) presented in the PHS Clinical Guidelines for Treating Tobacco Use and Dependence.

Attached, please find two documents that are designed to help guide clinicians integrate MI with the 5As/5Rs.

http://jeny.ipro.org/files/crespy/50OverFlowPic.jpg (http://jeny.ipro.org/attachment.php?attachmentid=597) An Overview Flowchart (http://jeny.ipro.org/attachment.php?attachmentid=597) (PHSMIOverFlow.doc) that provides a step by step approach to performing smoking cessation counseling.

http://jeny.ipro.org/files/crespy/50TeachingPic.jpg (http://jeny.ipro.org/attachment.php?attachmentid=596) A Teaching Flowchart Tool (http://jeny.ipro.org/attachment.php?attachmentid=596)(PHSMITeaching.doc ) that attempts to link together the 5Rs with features of Motivational Interviewing, demonstrating a brief clinical algorithm that attempts to cover both approaches simultaneously.

We welcome your comments and suggestions for improving these documents during this development phase. Ultimately we hope that they will be useful tools for those who conduct smoking cessation counseling and for those who teach others to perform this counseling.

It is my sincere hope that some of you will take a moment to contribute your impressions, reactions, thoughts and feedback by posting a message in this discussion.

Only by working together can we achieve the full potential for this collaborative and of this task. Thanks!

Scott Crespy, Ph.D.
IPRO Smoking Cessation Project Manager

[Linda Horton]

The tools that were recently posted - the overview flow chart and the teaching flow chart are both well done and could easily be used by staff as guides for smoking cessation counseling. Thank you to Scott for getting the links posted. For me the teaching flowchart was the easiest to apply - quick guides, easy questions to ask, quick focus on what you might say when at the bedside with a patient/family.
Linda Horton

[Fran Chambers]

I just reviewed the jeny web areas that you referrenced and the reference tools. In my opinion the tools are excellent. My suggestions for improvement include:

1. When viewing on the monitor screen, I think that the brightness of the red and blue are hard on the eyes.

2. When printing out on a black and white printer, the darkness of the background (created by the red and blue) makes reading the tool difficult.

3. I think that you have presented excellent information in a tool that has some design flaws (referenced above) which can be easily changed to make a truly functional asset to tobacco cessation efforts.

[Dorothy McMillin]

Part of Mercy Medical Centers smoking cessation project is to assist the patient through the acute phase of nicotine withdrawal by encouraging them to ask their physician to order nicotine replacement products. Being hospitalized with pneumonia,CHF or an MI is difficult enough without going through nicotine withdrawal. Bt spending time with the patient and discussing their options they feel like they are part of the treatment plan which could lead to a permanent cessation of smoking.

[Terry Miller]

Scott,

Thanks for the phone call. In reviewing the documents I find the flow charts to be very organized and informative.

What are your thoughts on providing a few motivational examples of open ended questions during the Ask and Access part of the intervention? During my trainings I have found that many were asking in a way that allows the patient to immediately say "No, I am not interested." An example may be something like "What are your thoughts and feelings about quitting?"

My second concern is this: when printed out in black and white there is not enough contrast and it is hard to read.

Terry Miller

[Scott Crespy]

Hi Linda, Fran, Dorothy & Terry,

Thanks for the observations and suggestions. Terry- Asking open-ended questions such as "What are your thoughts and feelings about quitting?" is an excellent way to engage the patient in a discussion about smoking. I agree, if you ask the question in such a way that the patient answers "No, I am not interested," how can a clinician then engage in a "motivational intervention" as is recommended in the Public Health Services Clinical Guidelines?

I would like to hear from others about this, but I am guessing that most hospitals are starting to put into place some systematic processes to determine whether or not the patient has a current or recent (in the last year) smoking history, the "ASK" (the 1st of the 5As). If this is asked in a matter-of-fact, non-judgmental way, patients are probably likely to answer this question, especially if it is in the context of their history and physical or other intake process, right?

I am guessing that a likely scenario is that the health-care worker will already know the patient's smoking status when attempting to make the opportunistic intervention, right? This is where introducing the topic may become a little more dicey. There are probably a number of ways that the provider can proceed from this point. I kind of like the suggestion made by Dr. Dunn made about the provider asking permission to discuss the topic. Perhaps after discussing one or more of the patient's immediate concerns, for example: Now that we took care of the room temperature, or drawing your blood, answering your question about your discharge, etc., would it be ok if we take a minute or two to touched base about your smoking?

The guidelines recommend providers give a strong message to the patient about quitting smoking. I seems that after the provider gives this advice, there is a lot of room to see how the advice is sitting with the patient and also to assess the patients view of their smoking. I think this may be an excellent place for the open-ended question that you have suggested. What do you think?

Dorothy- Thanks for reminding us that we can include the fact that the patient is for all practical purposes, "detoxing" from nicotine and that the health-care worker can almost immediately begin to foster a relationship of "patient advocate" by being concerned with the patient's comfort and by suggesting that the patient consider the use of NRTs! I would like to know how other think we can incorporate this as well.

We will definitely have to change the color schemes/layout design so that the documents will print better in black and white! Thanks.

Thanks for the feedback!


Scott Crespy, PhD
IPRO Smoking Cessation Project Manager

[Scott Crespy]

Thanks for sharing your suggestions to help improve these teaching tools that attempt to integrate elements of the Public Health Services Clinical Guidelines (i.e., 5As & 5Rs) with aspects of Motivational Interviewing.

On our Wednesday, February 2, 2005 smoking cessation collaborative conference call, Drs. Stimler, Chapman (http://www.robertchapman.net/), Skamai (http://www.downstate.edu/CHRP/ot/p6.html) and I reviewed the use of the two draft teaching tools (1. Overview Flowchart (http://jeny.ipro.org/attachment.php?attachmentid=597); 2. Teaching Flowchart (http://jeny.ipro.org/attachment.php?attachmentid=596) "Scales of Justice"). A 27.5 minute audio playback of this discussion is now available in three formats (Audio Help - What are the differences between these audio formats? (http://jeny.ipro.org/showthread.php?p=808#post808)):

MP3 Download (http://webmedia.ipro.org/smoking-cessation/PHSMI.mp3)
Windows Audio Stream (mms://webmedia.ipro.org/smoking-cessation/PHSMI.wma)
Real Audio Stream (rtsp://webstage.ipro.org/smoking-cessation/PHSMI.rm)
As these collaborative tools are still in a draft stage, please consider sharing your thoughts and reactions about them today. It is only through our joint effort can we begin to realize the potential of this task and our collaborative. Thanks!

Scott Crespy, PhD
IPRO Smoking Cessation Project Manager

[Scott Thomas]

This is a belated and overly long response to the Feb. 2nd conference call in which the flowcharts for inpatient smoking cessation were discussed. One flowchart integrates motivational interviewing (MI) with the Public Health Service 5A’s. On the call I questioned the logic for asking the patient for permission to discuss smoking and then immediately following up with an advice statement that they should quit.

Since this approach (asking permission and then immediately giving advice) does not seem to make sense from a basic counseling or MI point of view, I think it is worth taking a look at both why it is suspect and why we would want to pursue it. I believe it is suspect because asking permission gives the impression that there is going to be a sharing of viewpoints. It says, “let’s have a discussion about this.” To follow up with a “clear, strong” message that he or she should quit undermines the sense of reciprocity just offered (no matter how much empathy or humor is used). Or, more strongly put – it is a type of bait and switch. And while it can be very important for the provider to state his or her view, is there any necessity for it to be offered right at the start?

My answer would be, no. The only reason advice is being given at the start in lieu of what MI might encourage, is to stick with the order of the 5A’s (ask, advise, assess, assist arrange). However, I’ve been around cessation for some time and I'm at a loss to find any evidence that the 5A’s are more effective when done in any particular order. There is, of course, a logic to them. But, the evidence that supports them is either for each specific “A,” or for the increased effectiveness when more of the A’s are conducted. I imagine many a provider skips from Assess to Arrange when they are out of time, and know it is better to Assist the patient when they can adequately cover meds and referrals.

In a very nice discussion Scott Crespy and I had about all this after the call, we came to the rather obvious conclusion that when mixing MI and the 5A’s, the time at which the Advise statement is given is likely best left up to the provider. If a provider wants to offer it early on, he or she should do that. If it is left for the end as a nice summary statement, that would also likely work.

The trouble with this option is that it doesn’t make for a nice clean training tool. Sort of like the way the 5A’s is. Then again, the way the providers are often trained on the 5A’s goes against most principles of implementation and behavior change. To follow-up on that point of view, however, I will throw my two cents in on the Guidelines section (http://jeny.ipro.org/showthread.php?postid=836#post836).

Scott Thomas, PhD

[Scott Crespy]

Thanks for helping us begin to work through what may be the most conceptually awkward area of our efforts at combining the 5As and 5Rs from the PHS guidelines with aspects of Motivational Interviewing. Specifically the issue of having the provider give the patient advice just after asking for permission to discuss the topic. I think at this exact juncture (i.e., asking permission and then providing advice) is where two healthcare paradigms meet. This is where the traditional "provider-centered" advice giving comes into contact with the more "patient-centered" counseling style.

From the perspective of counseling theory, it may ultimately be more effective to have the provider skillfully work the advice later in the smoking cessation intervention, such as in the summary statement as you suggest. The question is how to best meet providers where they currently are in order to help bring them closer to appreciating that point. The proposed integrated model that we are discussing, in some ways is geared toward the provider audience and retains at least one definite "provider-centered" element - providing advice early on in the course of the intervention. As we are encouraging providers to begin to address the issue of smoking with their patients and to make changes themselves (i.e., in their practice style), the proposed model, attempts to meet the provider community fairly close to how they currently practice.

New elements are introduced into our model - asking for permission prior to giving advice and then seeking patient feedback after the advice is given. These may provide the early opportunities needed toward opening the door to establishing a more "collaborative" style between the provider and patient (which seems critical in issues of lifestyle change). Incorporating these practices into current advice-giving is hoped to lead to an increase in confidence and comfort in employing this type of a collaborative approach. As comfort increases and confidence grows, providers may begin to trust that they will have opportunities to provide advice further down the line in the cessation intervention.

Scott Crespy, PhD
IPRO Smoking Cessation Project Manager

[Karen Benker]

I find this discussion about Motivational Interviewing and the 5 A's very interesting. I believe that the 5 A's became the guideline for smoking cessation counseling by MDs because we're generally poorly taught communication skills---unlike other health professionals--- and this simple formulaic approach is a step forward from common practices of either ignoring smoking or barking out an order to the patient to quit.
It is a challenge to teach MI to MDs, but I have no doubt that MI a much more effective approach.

Personally I don't think we should try to meld MI into the 5 A's.

The challenge for us is two-fold:
establishing best methods of teaching MI to MDs
establishing the evidence base to show MI is superior to the 5 A's.
Then we'll be able to supplant the 5 A's with MI.

I recognize we're in a complicated situation because funding, etc. is often tied to use of the 5 A's. I'm comfortable passing out copies of the 5 A's because docs who aren't interested in improving their communication skills can apply this approach effectively. At the same time, we're teaching MI to those who are open to learning these skills.

I would be interested in hearing from folks who are teaching MI to MDs.

[Terry Miller]

I would suggest you visit the www.nysmokefree.com (http://www.nysmokefree.com)
At this site the NYS Cessation Center Collaborative Conference Call workgroup has posted several years worth of conference calls that have reached over 6000 physicains across NYS on a vaiety of topics that always include the use of the 5A's when working with a patient on addressessing their tobacco use and dependence. Included on this site are recordings and power points from Dr. Jonathan Foulds who is very wel spoken on MI and using MI technigues into the 5A's. this call was very well received, so we actually had a follow up call several months later.
Please go to:
www.nysmokefree.com (http://www.nysmokefree.com)
on the left side click on NYS Tobacco Control
Click on Collaborative conference call
on the page that comes up, near the bottom, click on Registration and call details
on page that comes up, near the top, in an orange colored bar, click on Previous. You will find all of our calls posted there. I hope you find these useful.
I would also suggest the January 2009 call with Dr. Micahel Cummings. he discusses the tobacco indusry tactics for getting and keeping our youth addicted to tobacco products.

[Jeffery]

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