liz macera, phd, anp-c, gnp-bc, achpn erin crawford, fnp-c ... · motivational interviewing...
TRANSCRIPT
![Page 1: Liz Macera, PhD, ANP-C, GNP-BC, ACHPN Erin Crawford, FNP-C ... · Motivational Interviewing Motivational Interviewing is a method that works on facilitating and engaging intrinsic](https://reader033.vdocuments.net/reader033/viewer/2022060403/5f0ea6677e708231d44042a9/html5/thumbnails/1.jpg)
Motivational Interviewing in Palliative Care Liz Macera, PhD, ANP-C, GNP-BC, ACHPN
Erin Crawford, FNP-C, GNP-BC, ACHPN
![Page 2: Liz Macera, PhD, ANP-C, GNP-BC, ACHPN Erin Crawford, FNP-C ... · Motivational Interviewing Motivational Interviewing is a method that works on facilitating and engaging intrinsic](https://reader033.vdocuments.net/reader033/viewer/2022060403/5f0ea6677e708231d44042a9/html5/thumbnails/2.jpg)
–George Bernard Shaw
“The single biggest problem in communication is the illusion that it has
taken place.”
![Page 3: Liz Macera, PhD, ANP-C, GNP-BC, ACHPN Erin Crawford, FNP-C ... · Motivational Interviewing Motivational Interviewing is a method that works on facilitating and engaging intrinsic](https://reader033.vdocuments.net/reader033/viewer/2022060403/5f0ea6677e708231d44042a9/html5/thumbnails/3.jpg)
Introductions
By show of hands
Where you work and area of specialization
![Page 4: Liz Macera, PhD, ANP-C, GNP-BC, ACHPN Erin Crawford, FNP-C ... · Motivational Interviewing Motivational Interviewing is a method that works on facilitating and engaging intrinsic](https://reader033.vdocuments.net/reader033/viewer/2022060403/5f0ea6677e708231d44042a9/html5/thumbnails/4.jpg)
Objectives
•Contrast salient palliative care issues at the time of diagnosis, mid disease, and end stage.
•Evaluate cultural and linguistic aspects that affect communication.
•Identify four methods of verbal reflection.
![Page 5: Liz Macera, PhD, ANP-C, GNP-BC, ACHPN Erin Crawford, FNP-C ... · Motivational Interviewing Motivational Interviewing is a method that works on facilitating and engaging intrinsic](https://reader033.vdocuments.net/reader033/viewer/2022060403/5f0ea6677e708231d44042a9/html5/thumbnails/5.jpg)
Today’s Session
• Review studies
• Skills & Practice
• Notice our own triggers & reactions
![Page 6: Liz Macera, PhD, ANP-C, GNP-BC, ACHPN Erin Crawford, FNP-C ... · Motivational Interviewing Motivational Interviewing is a method that works on facilitating and engaging intrinsic](https://reader033.vdocuments.net/reader033/viewer/2022060403/5f0ea6677e708231d44042a9/html5/thumbnails/6.jpg)
Exercise
![Page 7: Liz Macera, PhD, ANP-C, GNP-BC, ACHPN Erin Crawford, FNP-C ... · Motivational Interviewing Motivational Interviewing is a method that works on facilitating and engaging intrinsic](https://reader033.vdocuments.net/reader033/viewer/2022060403/5f0ea6677e708231d44042a9/html5/thumbnails/7.jpg)
Studies
•Many clinicians say communication with families is the most stressful part of their job
•Clinicians speak over 70% of the time
• McDonagh, et al. 2004
![Page 8: Liz Macera, PhD, ANP-C, GNP-BC, ACHPN Erin Crawford, FNP-C ... · Motivational Interviewing Motivational Interviewing is a method that works on facilitating and engaging intrinsic](https://reader033.vdocuments.net/reader033/viewer/2022060403/5f0ea6677e708231d44042a9/html5/thumbnails/8.jpg)
Pitfalls
1. Giving Pathophysiology Lectures
2. Forcing your agenda
3. Offering reassurance prematurely
4. Pushing the family to make a decision
5. Talking too much Arnold, R.,2010
![Page 9: Liz Macera, PhD, ANP-C, GNP-BC, ACHPN Erin Crawford, FNP-C ... · Motivational Interviewing Motivational Interviewing is a method that works on facilitating and engaging intrinsic](https://reader033.vdocuments.net/reader033/viewer/2022060403/5f0ea6677e708231d44042a9/html5/thumbnails/9.jpg)
Empathy
Brene Brown on The Power of
Empathy
http://youtube.be/1Evwgu369Jw
![Page 10: Liz Macera, PhD, ANP-C, GNP-BC, ACHPN Erin Crawford, FNP-C ... · Motivational Interviewing Motivational Interviewing is a method that works on facilitating and engaging intrinsic](https://reader033.vdocuments.net/reader033/viewer/2022060403/5f0ea6677e708231d44042a9/html5/thumbnails/10.jpg)
Empathy
How do you display empathy?
How do you recognize
empathy?
![Page 11: Liz Macera, PhD, ANP-C, GNP-BC, ACHPN Erin Crawford, FNP-C ... · Motivational Interviewing Motivational Interviewing is a method that works on facilitating and engaging intrinsic](https://reader033.vdocuments.net/reader033/viewer/2022060403/5f0ea6677e708231d44042a9/html5/thumbnails/11.jpg)
–Theodore Roosevelt
“People don’t care about how much you know till they know how much you care.”
![Page 12: Liz Macera, PhD, ANP-C, GNP-BC, ACHPN Erin Crawford, FNP-C ... · Motivational Interviewing Motivational Interviewing is a method that works on facilitating and engaging intrinsic](https://reader033.vdocuments.net/reader033/viewer/2022060403/5f0ea6677e708231d44042a9/html5/thumbnails/12.jpg)
Disease Trajectory
Needs early after diagnosis
Transition in the mid stages of disease
Late stages
![Page 13: Liz Macera, PhD, ANP-C, GNP-BC, ACHPN Erin Crawford, FNP-C ... · Motivational Interviewing Motivational Interviewing is a method that works on facilitating and engaging intrinsic](https://reader033.vdocuments.net/reader033/viewer/2022060403/5f0ea6677e708231d44042a9/html5/thumbnails/13.jpg)
Demo #1
• It happens everyday
• What did you see?
• How’s that working for you?
• What went right?
• What was the affect on communication?
![Page 14: Liz Macera, PhD, ANP-C, GNP-BC, ACHPN Erin Crawford, FNP-C ... · Motivational Interviewing Motivational Interviewing is a method that works on facilitating and engaging intrinsic](https://reader033.vdocuments.net/reader033/viewer/2022060403/5f0ea6677e708231d44042a9/html5/thumbnails/14.jpg)
Demo #2
• What was different?
• How did that feel as a family member?
• What was the result of the shift in method?
![Page 15: Liz Macera, PhD, ANP-C, GNP-BC, ACHPN Erin Crawford, FNP-C ... · Motivational Interviewing Motivational Interviewing is a method that works on facilitating and engaging intrinsic](https://reader033.vdocuments.net/reader033/viewer/2022060403/5f0ea6677e708231d44042a9/html5/thumbnails/15.jpg)
Tips
1.Recognize your own agenda
2. Sit down
3. Be curious- find out what they’re about
4. Listen
5. Ask permission
![Page 16: Liz Macera, PhD, ANP-C, GNP-BC, ACHPN Erin Crawford, FNP-C ... · Motivational Interviewing Motivational Interviewing is a method that works on facilitating and engaging intrinsic](https://reader033.vdocuments.net/reader033/viewer/2022060403/5f0ea6677e708231d44042a9/html5/thumbnails/16.jpg)
Body Language • Between 55 and 70%
communication is non-verbal
• In emotional situations body language usually prevails over words
• Patients feel vulnerable and search for non-verbal cues
Hall, Edward 1959
Weitz. W. (Ed). 1974 Stepanikova, Irena. 2004
![Page 17: Liz Macera, PhD, ANP-C, GNP-BC, ACHPN Erin Crawford, FNP-C ... · Motivational Interviewing Motivational Interviewing is a method that works on facilitating and engaging intrinsic](https://reader033.vdocuments.net/reader033/viewer/2022060403/5f0ea6677e708231d44042a9/html5/thumbnails/17.jpg)
Body Language
• Greet patient/family in a friendly manner
• Shake hands if culturally acceptable
• Sit down, eye on same level as patient
• Sit closest to patient
• Try and look relaxed even if you don’t feel it
![Page 18: Liz Macera, PhD, ANP-C, GNP-BC, ACHPN Erin Crawford, FNP-C ... · Motivational Interviewing Motivational Interviewing is a method that works on facilitating and engaging intrinsic](https://reader033.vdocuments.net/reader033/viewer/2022060403/5f0ea6677e708231d44042a9/html5/thumbnails/18.jpg)
Body Language • Feet flat on ground
• Heels and knees together
• Shoulders dropped
• Hands flat in lap
• Smile
• Make eye contact (while family talking)
• Break eye contact (if angry or crying)
Buckman, Robert. MD. 2009
![Page 19: Liz Macera, PhD, ANP-C, GNP-BC, ACHPN Erin Crawford, FNP-C ... · Motivational Interviewing Motivational Interviewing is a method that works on facilitating and engaging intrinsic](https://reader033.vdocuments.net/reader033/viewer/2022060403/5f0ea6677e708231d44042a9/html5/thumbnails/19.jpg)
Listening Posture
• Keep your lips pressed together
• Nodding, smiling
• “Uh-hmm”
• Avoid interrupting
• Slight lean forward Buckman, Robert. MD. 2009
![Page 20: Liz Macera, PhD, ANP-C, GNP-BC, ACHPN Erin Crawford, FNP-C ... · Motivational Interviewing Motivational Interviewing is a method that works on facilitating and engaging intrinsic](https://reader033.vdocuments.net/reader033/viewer/2022060403/5f0ea6677e708231d44042a9/html5/thumbnails/20.jpg)
Universal Emotions •Happiness
•Sadness
•Anger
•Disgust
•Contempt
•Surprise
http://www.ekmaninternational.com/paul-ekman-interanatonal-pic-home.aspx
![Page 21: Liz Macera, PhD, ANP-C, GNP-BC, ACHPN Erin Crawford, FNP-C ... · Motivational Interviewing Motivational Interviewing is a method that works on facilitating and engaging intrinsic](https://reader033.vdocuments.net/reader033/viewer/2022060403/5f0ea6677e708231d44042a9/html5/thumbnails/21.jpg)
Cues to Avoid • Tapping fingers, pens,
pencils
• Clenching fists
• Yawning
• Looking out the window
• Tapping your feet
• Crossing arms or legs
• Shifting weight from one foot to another
Rogers, C. 2002
![Page 22: Liz Macera, PhD, ANP-C, GNP-BC, ACHPN Erin Crawford, FNP-C ... · Motivational Interviewing Motivational Interviewing is a method that works on facilitating and engaging intrinsic](https://reader033.vdocuments.net/reader033/viewer/2022060403/5f0ea6677e708231d44042a9/html5/thumbnails/22.jpg)
––Henry Wadsworth Longfellow
“Do not condemn the judgement of another because it differs from your own. You may both be
wrong”
![Page 23: Liz Macera, PhD, ANP-C, GNP-BC, ACHPN Erin Crawford, FNP-C ... · Motivational Interviewing Motivational Interviewing is a method that works on facilitating and engaging intrinsic](https://reader033.vdocuments.net/reader033/viewer/2022060403/5f0ea6677e708231d44042a9/html5/thumbnails/23.jpg)
Motivational Interviewing
Motivational Interviewing is a method that works on facilitating and engaging intrinsic motivation within the client in order to change behavior. MI is a goal-oriented, client-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence.
![Page 24: Liz Macera, PhD, ANP-C, GNP-BC, ACHPN Erin Crawford, FNP-C ... · Motivational Interviewing Motivational Interviewing is a method that works on facilitating and engaging intrinsic](https://reader033.vdocuments.net/reader033/viewer/2022060403/5f0ea6677e708231d44042a9/html5/thumbnails/24.jpg)
Hidden Dynamics
• Resistance
• Patient/family resist discussing the future
• Disagree with clinician’s point of view
• Argue against the treatment plan
![Page 25: Liz Macera, PhD, ANP-C, GNP-BC, ACHPN Erin Crawford, FNP-C ... · Motivational Interviewing Motivational Interviewing is a method that works on facilitating and engaging intrinsic](https://reader033.vdocuments.net/reader033/viewer/2022060403/5f0ea6677e708231d44042a9/html5/thumbnails/25.jpg)
Hidden Dynamics
• Ambivalence
• Sometimes patients and families are ambivalent and unable to make a decision
• They may be forced to choose between two undesirable options
![Page 26: Liz Macera, PhD, ANP-C, GNP-BC, ACHPN Erin Crawford, FNP-C ... · Motivational Interviewing Motivational Interviewing is a method that works on facilitating and engaging intrinsic](https://reader033.vdocuments.net/reader033/viewer/2022060403/5f0ea6677e708231d44042a9/html5/thumbnails/26.jpg)
“A practitioner who is listening, even if it is for just a minute, has no other immediate agenda than to understand the other person’s perspective and experience.” (Rollnick, Miller, and Butler, 2008, pg. 66.)
![Page 27: Liz Macera, PhD, ANP-C, GNP-BC, ACHPN Erin Crawford, FNP-C ... · Motivational Interviewing Motivational Interviewing is a method that works on facilitating and engaging intrinsic](https://reader033.vdocuments.net/reader033/viewer/2022060403/5f0ea6677e708231d44042a9/html5/thumbnails/27.jpg)
Motivational Interviewing
R- Resist the Righting Reflex
U-Understand the patient’s motivation
L-Listen
E- Empower the patient
![Page 28: Liz Macera, PhD, ANP-C, GNP-BC, ACHPN Erin Crawford, FNP-C ... · Motivational Interviewing Motivational Interviewing is a method that works on facilitating and engaging intrinsic](https://reader033.vdocuments.net/reader033/viewer/2022060403/5f0ea6677e708231d44042a9/html5/thumbnails/28.jpg)
Reflective Listening Skills
• Open-ended questions
• Repeating
• Rephrasing
• Paraphrasing
• Reflecting
![Page 29: Liz Macera, PhD, ANP-C, GNP-BC, ACHPN Erin Crawford, FNP-C ... · Motivational Interviewing Motivational Interviewing is a method that works on facilitating and engaging intrinsic](https://reader033.vdocuments.net/reader033/viewer/2022060403/5f0ea6677e708231d44042a9/html5/thumbnails/29.jpg)
Open-Ended Questions
What do you understand about your condition?
How do you think you loved one is doing?
What complications are you aware of that may occur?
What do you understand about CPR?
What would your loved one say if they could talk?
![Page 30: Liz Macera, PhD, ANP-C, GNP-BC, ACHPN Erin Crawford, FNP-C ... · Motivational Interviewing Motivational Interviewing is a method that works on facilitating and engaging intrinsic](https://reader033.vdocuments.net/reader033/viewer/2022060403/5f0ea6677e708231d44042a9/html5/thumbnails/30.jpg)
Reflective Listening Simple Reflections
•Repeating-
• repeat an element of what was said
•Rephrasing-
• re-word without interpretation
![Page 31: Liz Macera, PhD, ANP-C, GNP-BC, ACHPN Erin Crawford, FNP-C ... · Motivational Interviewing Motivational Interviewing is a method that works on facilitating and engaging intrinsic](https://reader033.vdocuments.net/reader033/viewer/2022060403/5f0ea6677e708231d44042a9/html5/thumbnails/31.jpg)
Reflective Listening Deeper Reflections
•Paraphrasing - infers meaning
• Statement: I don’t like thinking about the possibility of being in an nursing home.
• Reflection: Being in a nursing home would be unacceptable to you.
![Page 32: Liz Macera, PhD, ANP-C, GNP-BC, ACHPN Erin Crawford, FNP-C ... · Motivational Interviewing Motivational Interviewing is a method that works on facilitating and engaging intrinsic](https://reader033.vdocuments.net/reader033/viewer/2022060403/5f0ea6677e708231d44042a9/html5/thumbnails/32.jpg)
Reflective Listening Deeper Reflections
•Reflection of Feeling- emphasizes emotional content
• Statement: I don’t want to suffer. My mother did and it was awful.
• Reflection: The thought of suffering really upsets you.
![Page 33: Liz Macera, PhD, ANP-C, GNP-BC, ACHPN Erin Crawford, FNP-C ... · Motivational Interviewing Motivational Interviewing is a method that works on facilitating and engaging intrinsic](https://reader033.vdocuments.net/reader033/viewer/2022060403/5f0ea6677e708231d44042a9/html5/thumbnails/33.jpg)
Skills Practice
•Approach /Avoid Exercise
•Open-ended questions and reflections
•60 year old diabetic “non-compliant” female w/foot ulcer
![Page 34: Liz Macera, PhD, ANP-C, GNP-BC, ACHPN Erin Crawford, FNP-C ... · Motivational Interviewing Motivational Interviewing is a method that works on facilitating and engaging intrinsic](https://reader033.vdocuments.net/reader033/viewer/2022060403/5f0ea6677e708231d44042a9/html5/thumbnails/34.jpg)
Other techniques
• Normalize
• Often families of people with
• Feel a bit awkward about making a loved one DNR. Do you have any of those feelings?
• Silence
Acknowledge
This must be difficult
I can’t imagine how hard this must be
Validate
You are doing exactly what an agent should do
![Page 35: Liz Macera, PhD, ANP-C, GNP-BC, ACHPN Erin Crawford, FNP-C ... · Motivational Interviewing Motivational Interviewing is a method that works on facilitating and engaging intrinsic](https://reader033.vdocuments.net/reader033/viewer/2022060403/5f0ea6677e708231d44042a9/html5/thumbnails/35.jpg)
Explore for Meaning Helpless Just pull the plug Tough it out
Dignity Useless Existence I can still beat it
Control Nothing else can be done I’m not dead yet
Hopeless Dependent on others I’m a fighter
Suffering No way to live I believe in miracles
Lingering I have faith in God Not going to give up
Vegetable Don’t want to be a burden I can’t do anything
Burden Vegetable
Suffer Do things right
![Page 36: Liz Macera, PhD, ANP-C, GNP-BC, ACHPN Erin Crawford, FNP-C ... · Motivational Interviewing Motivational Interviewing is a method that works on facilitating and engaging intrinsic](https://reader033.vdocuments.net/reader033/viewer/2022060403/5f0ea6677e708231d44042a9/html5/thumbnails/36.jpg)
Common Concerns
Patient
• Silent due to denial, fear or painfulness of conversation
• Suspicious about provider’s motive for discussion
• Other priorities, symptoms/finances/family stress Agent
![Page 37: Liz Macera, PhD, ANP-C, GNP-BC, ACHPN Erin Crawford, FNP-C ... · Motivational Interviewing Motivational Interviewing is a method that works on facilitating and engaging intrinsic](https://reader033.vdocuments.net/reader033/viewer/2022060403/5f0ea6677e708231d44042a9/html5/thumbnails/37.jpg)
Common Concerns
Agent
• Dominates conversation
• Wishes are in conflict with patient
• Stronger personality than patient
• ANGRY family
![Page 38: Liz Macera, PhD, ANP-C, GNP-BC, ACHPN Erin Crawford, FNP-C ... · Motivational Interviewing Motivational Interviewing is a method that works on facilitating and engaging intrinsic](https://reader033.vdocuments.net/reader033/viewer/2022060403/5f0ea6677e708231d44042a9/html5/thumbnails/38.jpg)
Working with Interpreters • Prepare the interpreter before the meeting and debrief afterwards
•Use first person and talk directly to the patient/family
• Maintain eye contact
• Minimize jargon; avoid humor, metaphor, proverb
•Give information in short bits and pause for interpretation (1-2 sentences)
•To test understanding ask the patient/family to repeat If you need to talk directly to the interpreter, use his/her name or “interpreter
• For more information: https://www.aamc.org/students/download/70338/data/interpreter-guidelines.pdf
![Page 39: Liz Macera, PhD, ANP-C, GNP-BC, ACHPN Erin Crawford, FNP-C ... · Motivational Interviewing Motivational Interviewing is a method that works on facilitating and engaging intrinsic](https://reader033.vdocuments.net/reader033/viewer/2022060403/5f0ea6677e708231d44042a9/html5/thumbnails/39.jpg)
Working with Hearing Loss
• Ask if patient has hearing aids or uses an assistive device
• Ask family or caregiver for tips on how best to communicate
• Minimize background noise
• Use a deep voice
• Look directly at the patient
![Page 40: Liz Macera, PhD, ANP-C, GNP-BC, ACHPN Erin Crawford, FNP-C ... · Motivational Interviewing Motivational Interviewing is a method that works on facilitating and engaging intrinsic](https://reader033.vdocuments.net/reader033/viewer/2022060403/5f0ea6677e708231d44042a9/html5/thumbnails/40.jpg)
Working with Hearing Loss
• Slow down and speak clearly
• Use written communication to supplement important points
• Paraphrase rather than repeat
• Consider using a amplifier, pocket talker
• If person skilled in ASL, use an interpreter
http://ucsfhealth.org/education/communicating with people with hearing loss/
![Page 41: Liz Macera, PhD, ANP-C, GNP-BC, ACHPN Erin Crawford, FNP-C ... · Motivational Interviewing Motivational Interviewing is a method that works on facilitating and engaging intrinsic](https://reader033.vdocuments.net/reader033/viewer/2022060403/5f0ea6677e708231d44042a9/html5/thumbnails/41.jpg)
Resources Arnold R. et al. (2010). Educational modules for the critical care communication (C3) course-A communication skills training program for intensive care fellows
Back A, Arnold R, Tulsky J. (2009) Mastering Communication with Seriously Ill Patients. Cambridge University Press: New York.
Buckman, R. (2009) Non-verbal communication.Communication skills.http://www.mdanderson.org/transcripts/icare_NonVerbComm.htm.
Hall, E.T. (1959). Silent Language. New York:Doubleday & Co.
Matulich, Bill (2013) How to do Motivational Interviewing: A Guidebook, Second Edition.
Miller, WR & Rollnick, S. (2012) Motivational Interviewing: Helping People Change, Third Edition. The Guilford Press: New York.
![Page 42: Liz Macera, PhD, ANP-C, GNP-BC, ACHPN Erin Crawford, FNP-C ... · Motivational Interviewing Motivational Interviewing is a method that works on facilitating and engaging intrinsic](https://reader033.vdocuments.net/reader033/viewer/2022060403/5f0ea6677e708231d44042a9/html5/thumbnails/42.jpg)
Resources
Rogers, C. (2002) Your body language speaks loudly:Nonverbal communication makes patients more comfortable. Academy News. http://www2.aaos.org/acadnews/2002news/b16-7.htm
Weitz, W. (Ed.) (1974). Nonverbal Communication. London:Oxford University Press
www.motivationalinterviewing.org
www.motivationalintervieingonline.com