Lecture_3_Doctor/Pt. Relationship III_Facilitating Pt. Cooperation & Behavioral Change--Motivational Interview & the Transtheoretical Model Flashcards
1
Q
Identify two ways to facilitate patient engagment:
Patient Engagement:
Common errors leading to disengagement during the interview
A
- too much of a “getting right down to business” style
- staying in the biomedical sphere & failing to demonstrate an understanding of patient concerns, beliefs, and worries.
- inadvertently shaming, embarrassing or humilitating the pt.
- can be result of oversimplifying the problem
- finding fault with or blaming the pt.
- a focus on assessment to the exclusion of the relationship
- drawing premature conclusions
- about the nature of the problem
- offering premature solutions or advice
- assuming a common understanding
- spending too much time in social chit-chat
2
Q
Identify two ways to facilitate patient engagement:
Historical Interventions & Outcomes (incorrect attempts/views)
A
- reapeatedly educating pts.
- not usually successful, and
- frustrating for both physician & pt.
- promising an improved outcome
- does not guarantee motivation for long-term change
- confronting the pt.
- viewed by pts as critical & non-supportive
- BUT, it can be done w/care
- viewed by pts as critical & non-supportive
- viewing relapse as a failure
- by pt and/or physician
- labeling pts
- questions the pt’s character, and
- ignores the complexity of the behavior change process
3
Q
Identify two ways to facilitate pt. engagement:
Engagement process:
- when does it begin?
- what is it?
- what is necessary for it?
A
- engagement begins immediately
- it’s an attitude, not a technique
- some interview styles are more conducive to creating this than others (must have mutual trust/respect demonstrated, not just in words)
- process by which doctor & pt initiate and maintain an effective working relationship
- based on mutual trust and respect,
- a physician’s clearly articulated and demonstrated concern for pt’s welfare
4
Q
Identify two ways to facilitate pt. engagement:
Types of Interview Questions:
- what are the two types of questions?
- what is the difference?
- how can they be answered by pt?
- how can they be initiated by physician?
A
Open-ended
- requires more than a yes or no
- invites the telling of story
- invites spontaneous and unguided responses & expression
- builds rapport
- ways to begin:
- “tell me about…”
- “how would you describe….”
Closed-ended
- can be answered with a short response or a yes or no
- useful and quick
- may be necessary, depending on the situation at hand
- limits story telling
- is clinician driven & focused
- patient can remain passive & disengaged
- often begins with:
- “did you…”
- “have you ever…”
5
Q
Identify two ways to facilitate pt. engagement:
Evocative Questions:
- what do they do?
- how do they help clinician gather information?
- examples?
A
calls forth something from the patient
- typically open-ended
- helps clinician gather self-motivational statements about:
- self-acknowledged reasons for change
- intentions to change
- advantages to change
- disadvantages to the status quo
Examples:
- “If you were to change, what would be the best result(s) you can imagine?”
- “Suppose you continue as you have been without changing, what might your life be like 10 years from now?”
- “What worries you most about your condition?”
- “How does you condition stop you from doing the things you want to do?”
6
Q
Identify two ways to facilitate patient engagement:
What are some evocative questions that you could ask Sam, the pot smoker?
A
- “How do you think quitting smoking would affect your relationships?”
- “Tell me some of the benefits you experience from smoking?”
- “We spoke about the consequences of quitting, what are some of the benefits to quitting?”
- “What brought you into my office today?”
- “How do you think smoking will affect your future self?”
- “How does it affect your daily life?”
7
Q
Identify two ways to facilitate pt engagement:
Reflective Listening:
- What is it?
- What are its purposes?
- What are the types of reflection available in your toolkit?
- What do each of them offer you as tools?
A
- What is it?
- reflecting what you hear the pt. saying, or what you believe the pt. means.
- What are its purposes?
- keeps a pt. talking and thinking, and going deeper into self and the topic
- to gain understanding of pt’s perspective
- lets pt. know you’re listening
- diffuses resistance
- checks out assumptions
- corrects misperceptions
- What are the types of reflection available in your toolkit? What do each of them offer you as tools?
- repeating
- simplest form; diffuses resistance (if well done)
- Pt. “I don’t want to quit smoking”
- Cl. “You don’t want to quit smoking”
- simplest form; diffuses resistance (if well done)
- rephrasing
- slightly alters pt’s words to lift up & emphasize the meaning behind the words
- can help pt. move forward
- Pt. “I really want to quit smoking”
- Cl. “Quitting smoking is important to you.”
- empathic reflection
- conveys understanding of pt’s situation
- builds rapport and decreases resistance
- Pt. “What do you know about quitting? You probably never smoked.”
- Cl. “It’s hard to imagine how I could understand your dilemma.”
- reframing
- helps pt. think about a situation differently by providing a different point of emphasis
- Pt. “I’ve tried to quit and failed so many times.”
- Cl. “You are persistent, even in the face of disappointment. Stopping smoking sounds very important to you.”
- helps pt. think about a situation differently by providing a different point of emphasis
- double-sided reflection
- acknowledges both sides of ambivalence
- Pt. “Smoking helps me relieve stress.”
- Cl. “On the one hand, smoking helps you reduce stress. On the other hand, you’ve said it creates stress by causing you to cough, spend money, and worry about your health.”
- acknowledges both sides of ambivalence
- repeating
8
Q
Identify factors likely to influence patient success with change:
Building a base for change–strategies to facilitate change in pt.
- What are the 5 strategies for building a base for change?
A
- affirmation
- intention & commitment
- elicit “change talk”
- express optimism
- summarize
9
Q
Identify factors likely to influence patient success with change:
Building a base for change–strategies to facilitate change in pt.
Affirmation:
- what is it?
- what are some examples of affirmation-talk that HCP can give?
A
- affirmation is one way to build self-efficacy
- it allows HCP to connect with pt by giving praise/encouragement in order to boost confience/efficacy
- examples:
- “It says a lot that you took the step in coming here today.”
- “You have a lot of courage to take such a hard look at this/”
- “I have enjoyed talking with you today, and getting to know you a bit/”
- “If I were in your position, I might have a difficult time with this also.”
10
Q
Identify factors likely to influence patient success with change:
Building a base for change–strategies to facilitate change in pt.
Intention & Commitment:
- what is it?
- what are some examples of intention & commitment-talk that HCP can give?
A
- explore and encourage intention
- look for and lift up commitment
- examples:
- “how important is this to you?”
- “how much do you wnat to do this?”
- “how confident are you that you can make this change?”
- “I can see that you are feeling stuck at this moment. What is going to have to change?”
11
Q
Identify factors likely to influence patient success with change:
Building a base for change–strategies to facilitate change in pt.
Elicit “Change Talk”:
- what is it?
- what are some examples of eliciting change-talk that HCP can give?
A
- showcases the disadvantages of the status quo
- “What worries you about your current situation?
- “What makes you think that you need to do something about your situation?”
- “What do you think will happen if you do not change anything?”
- advantages of change (pros vs. cons, benefits vs. burdens)
- “What would be the good things about changing your situation (i.e. losing weight, quitting smoking, etc.)?”
- The fact that you’re here indicates at least part of you thinks that it is time to do something. What are the main reasons you want to make a change?”
12
Q
Identify factors likely to influence patient success with change:
Building a base for change–strategies to facilitate change in pt.
Express Optimism:
- what is it?
- what are some examples of express optimism-talk that HCP can give?
A
- encourage hope, support & self efficacy
- “What do you think would work for you if you decided to change?”
- What personal strengths can you use to help you succeed?”
- Identify & mobilize support network
- “Who could offer you helpful support in making this change?”
- get family/support network involved
- if it’s not there, help them find one
13
Q
Identify factors likely to influence patient success with change:
Building a base for change–strategies to facilitate change in pt.
Summarize:
- what is it?
- why should a HCP do it?
- how often?
- what are some examples of summarize-talk that HCP can give?
A
- summary statement link together and reinforce material discussed
- think of it as a form of reflection
- it communicates you have heard the pt.
- also gives you time to think about what you’re going to do/say next
- excellent way to begin a transition to a different place in the interview process
- helps to set the frame for another area of inquiry
- summarize frequently–especially at points of transition in the interview
- you probably can’t summarize too much
- below is an example of summarizing ambivalence:
- “You appear inclined in two different directions. On the one hand, you are somewhat worreid about possible long-term effects of X (diabetes) if you don’t manage it well–blindness, amputations, things like that. On the other hand, you are young and you feel fairly healthy most of the time. You enjoy eating what you like, and any long-term consequences seem far away. You are concerned, and at the same time you are not concerned.”
14
Q
Define basic elements of motivational interviewing:
Motivational Interviewing:
- what is it?
- what must happen before educating a patient and problem-solving?
- what is it’s purpose?
- what does it focus on?
- what does it NOT do?
- why is it called interviewing?
- how quickly do you want to do this?
A
- what is it?
- a method to engage pts as collaborators in health behavior changes & facilitate pt motivation for change
- what must happen before educating a patient and problem-solving?
- building a pt’s motivation for behavioral change
- building pt’s motivation for treatment
- what is it’s purpose?
- it is a pt-clinician communication designed to resolve ambivalence and build motivation for behavior change
- what does it focus on?
- creating a comfortable atmosphere without coercion to change
- what does it NOT do?
- provide pts with solutions or problem-solving until they make a decision to change
- relies upon shared decision-making
- provide pts with solutions or problem-solving until they make a decision to change
- why is it called interviewing?
- called interviewing because it requires careful listening and strategic questioning
- how quickly do you want to do this?
- you don’t want to rush this. it’s something that the pt will eventually direct themselves if you guide them correctly.
15
Q
Define basic elements of motivational interviewing:
Motivational Interviewing:
- What is the “spirit of motivational interviewing?
- what are examples under each of the 4 categories?
A
- Collaboration
- a partnership
- acceptance
- absolute worth
- affirmation
- autonomy
- accurate empathy
- compassion
- “a deliberate commitment to pursue the welfare and best interests of the other.”
- evocation
- draw out vs. lecture or insert
