APNA 29th Annual Conference Session 2037: October 29, 2015 Kristin - - PDF document

APNA 29th Annual Conference Session 2037: October 29, 2015 McKenzie 1

Kristin McKenzie DNP , PMHNP-BC

• Funding for this study was supported by a Coletta A. Klug Fund

Award, The State University of New York, University at Buffalo, 2012 & 2013.

• The study findings have been published in Perspectives of

Psychiatric Care, ISN 00315990. “The Effect of Nurse-Led Motivational Interviewing on Medication Adherence in patients with Bipolar Disorder. Written by Kristin McKenzie DNP , PMHNP and Yu-Ping Chang PhD, RN.

• The speaker has no conflicts of interest to disclose.
• 1. Review the procedures and outcomes of a pilot study that

utilized Motivational Interviewing to improve medication adherence in client’s with Bipolar Disorder.

• Discuss a theoretical model of adherence, and how motivational

interviewing can be used to address medication taking behaviors.

• 2. Explore how evidence can be translated into clinical nursing

practice in the outpatient mental health setting

APNA 29th Annual Conference Session 2037: October 29, 2015 McKenzie 2

• Bipolar Disorder (BD) treatment outcomes and prognosis are dependent upon

medication adherence, yet non-adherence rates average between 35-60% for this population. (Berk et al., 2010; Sajatovic, Valenstein, Blow, Ganoczy, & Ignacio, 2006; NIMH, 2008; Otto, Reilly-

Harrington, & Sachs, 2003; Scott & Tacchi, 2002; Stahl, 2009).

• Lack of Evidence-based Nursing Interventions or Standards of Practice for

promoting medication adherence in outpatient psychiatry (APA, 2002; NIMH, 2008)

• Need for an applicable nursing theory and model of adherence to support

further use of MI by psychiatric nurses * See Handout (Adamian, et al., 2004)

• Four principles of MI:
• 1. Express Empathy
• 2. Develop Discrepancy
• 3. Support Self Efficacy
• 4. Roll with Resistance
• The Spirit of MI:
• Collaboration- Build rapport with empathy and understanding
• Autonomy- Explore Internal Motivators + Barriers to Change
• Evocation- Reflective statements, Empowerment, Praise

APNA 29th Annual Conference Session 2037: October 29, 2015 McKenzie 3

Medication Adherence Rating Scale (MARS)

Sajatovic, et al. (2010), Thompson, et al. (2000).

Timeline Follow Back (TLFB)

Braithewait et al. (2005)

Motivational Rulers (MIR)

Miller & Rollnick (2002)

Self-Efficacy and Appropriate Medication use Scale (SEAMS) Risser, Jacobson, & Kripalani (2007) Patient Satisfaction Questionnaire

• Aim 1: To measure changes in medication adherence by

comparing pre and post scores on the MARS & TLFB calendar during a one month MI intervention

• Aim 2: To determine if the MIR and the SEAMS can

demonstrate change in scores collected over a three week intervention period.

• Aim 3: To evaluate treatment satisfaction after three MI

sessions using the Participant Satisfaction Questionnaire

INTERVENTION

• Exploratory Pretest-Posttest design
• Intervention Manuscript used by PI during all 3 MI interventions.
• Participant Packet sent home to complete during telephone sessions.

APNA 29th Annual Conference Session 2037: October 29, 2015 McKenzie 4

4 week Motivational Interviewing intervention * See Handout

• 1. MI Session 1: Onsite 1:1 intervention = 35-60 minutes
• 2. MI Session 2: Telephone session = 10-25 minutes
• 3. MI Session 3: Telephone session = 15-25 minutes
• 4. Post-test: Onsite follow-up testing = 10-15 minutes

INTERVENTION

• SAMPLE
• 14 total participants received MI and completed post-test
• All Caucasian, English speaking, w/Bipolar 1, 2 or NOS diagnosis
• 11 Females, 4 Males
• Age range 23-57 years old, with a mean age of 35 (11.1)
• 80% (N=12) of subjects graduated from high school
• DATA ANALYSIS
• Descriptive Statistics: Measure of variability and central tendency
• Paired Samples T-tests: Pre-Post data from MARS, TLFB, and SEAMS
• Repeated measures ANOVA on Pre-Mid-Post data from MIR and SEAMS

APNA 29th Annual Conference Session 2037: October 29, 2015 McKenzie 5

Study Outcomes

• Aim 1: Review of the MARS and TLFB showed a significant increase in

medication adherence at 30 day post-test.

• Aim 2: MIR showed a progressive ↑ in individual and total scores when

rating Importance, Motivation and Confidence to change medication taking

• behavior. SEAMS demonstrated steady increase in scores over a 4 week

period

• Aim 3: Overall Patient Satisfaction ranked between 4.6 and 5 /5= good

to very good ratings; reflecting level of comfort with PI and the PI sensitivity to their needs during intervention

• Pre-intervention testing showed participants started with moderate medication

adherence scores on TLFB and MARS

• Individual questions helped identify areas that needed change, which ultimately

resulted in improved medication adherence

• Self-efficacy is a causal element of change, and breakdown of collected data

showed that self-evaluation skills and building confidence made a positive impact on adherence

• Statistically Identified Barriers to Adherence:

Forgetfulness, Medication side effects, and Daily routine

Study Limitations

• small homogenous sample
• poor external and internal validity
• lacking objective and longitudinal data
• no double blind

APNA 29th Annual Conference Session 2037: October 29, 2015 McKenzie 6

• MI Techniques applied in this study:
• Discuss past/current experiences along with personal beliefs about medication
• Provide empathy; Recognize and praise “change talk”; Use reflective listening
• Assess readiness to change; Assist personal goal development; Support Self-Efficacy
• The SEAMS and MIR can identify progressive change throughout MI intervention, and

Pre/Post testing with MAR and TLFB can demonstrate change at one month follow-up

• The application of fundamental elements of MI and the utilization of evidence-

based rating scales can improve medication adherence when used in outpatient psychiatry.

• Motivational Interviewing Training: Nurses require adequate training for

the application of MI techniques in clinical practice

• Future Nursing Research:

1. Expand clinical trials to provide a higher level of scientific evidence 2. Test and implement the use of medication adherence assessment tools

• Client’s with Bipolar Disorder can change medication taking

behaviors after 3 brief MI interventions

• This Pilot study contributes to current evidence that supports the

use of nurse-led motivational interviewing in outpatient mental health settings to improve medication adherence.

• Need for further Nursing Research to inform clinical practice

and promote the use of MI techniques as a standard of care for

• utpatient medication management

APNA 29th Annual Conference Session 2037: October 29, 2015 McKenzie 7

Please take time to complete post-test questions, thank you

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