Having Difficult Conversations: Working through Conflict and - - PDF document

9/26/2016 1 Having Difficult Conversations:

Working through Conflict and Uncertainty with Motivational Interviewing

Presented by: Alison Dent, Immunize Oregon Coordinator Alyssa McClean, Oregon AWARE Coordinator

Agenda

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• Introductions
• Controversy in Oregon

– Antibiotic resistance – Vaccine hesitancy

• Difficult conversations

– Realities – Principles – Techniques

• Behavior Change Models
• Motivational interviewing

– Basics – Demonstration

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ANTIBIOTIC RESISTANCE

Oregon AWARE

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http://www.cdc.gov/getsmart/community/images/materials/ar-deaths.jpg

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Antibiotic use

• Unnecessary Prescribing

– 1/3 of all antibiotic prescriptions are inappropriate – 50% of respiratory infections receive unnecessary treatment – 80% of those receive broad spectrum antibiotics

• Financial Burden

– $1.1 billion is spent annually for adult URI infections – Over 60% of antibiotic expenditures in US occurs in outpatient settings

8 Tamma, Pranita D, Cosgrove, Sara E. Addressing the Appropriateness of Outpatient Antibiotic Prescribing in the United States: An Important First Step. JAMA. 2016;315(17):1839-1841. Shapiro DJ, Hicks LA, Pavia AT, Hersh AL. Antibiotic prescribing for adults in ambulatory care in the USA, 2007–09. J Antimicrob Chemother. 2014;69(1):234-40 For the spending in outpatient settings: Suda KJ, Hicks LA, Roberts RM, Hunkler RJ, Danziger LH. A national evaluation of antibiotic expenditures by healthcare setting in the United States, 2009. J 9

Proportion of patients filling antibiotic prescriptions, by age group, Oregon, 2013

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Broad vs. narrow spectrum antibiotic use among patients filling antibiotic prescriptions, Oregon, 2013

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Proportion of patients filling antibiotic prescriptions vs proportion needing antibiotics, Oregon, 2013

68 62 28 49 11 65 40 25 10 5

10 20 30 40 50 60 70 80 Acute Otitis Media Sinusitis Pharyngitis Bronchitis Common Cold Percent Received Antibiotic Likely Needed Antibiotic

VACCINE HESITANCY

Immunize Oregon

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Gust, et al. American Journal of Health Behavior, 2005 http://www.ncbi.nlm.nih.gov/pubmed/15604052#sthash.TRm8qr3T.dpuf

Categorization of Attitudes Toward Vaccines

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Senate Bill 895 (2015-2016)

Key changes made by Senate Bill 895

• Religious exemptions signed prior to March 1,

2014, are no longer valid.

• Schools and children’s facilities are required to

have immunization and exemption rates available at main offices, on websites, and for parents on paper or electronic format.

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https://public.health.oregon.gov/PreventionWellness/VaccinesImmunization/G ettingImmunized/Pages/SchResources.aspx

DIFFICULT CONVERSATIONS

Realities, principles, techniques

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“I realized that I was never going to get at the heart of the issue because these fears weren’t so much about facts as they were about emotions. The fears themselves are contagious, and have their own emotional epidemiology”

• Danielle Ofri, MD

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Human nature

• Bring negative assumptions into the

conversation

• Spend “listening” time crafting rebuttals
• Don’t address core issues

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Realities of a conversation

• Difficult conversations are inevitable
• Sometimes conversations will end in resolution
• Sometimes conversations will end in

compromise

• Sometimes they will just end

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Realities of time

• Short patient interactions

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Techniques: Active Listening

• Active listening

– Seek to understand before you seek to be understood – Be non judgmental – Give your undivided attention to the speaker – Use silence effectively

http://www.state.gov/m/a/os/65759.htm

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Techniques: Participatory Vs. Presumptive

• Participatory

– "Do you want to vaccinate your child today?“ – "What do you think about vaccines?“ – "Would you like to hear about the vaccines we offer for today's visit?"

• Presumptive

– "Today your child is due for 2 vaccines. We will be giving MMR and Varicella.“ – "It's time for an annual influenza vaccine. Your child is old enough to receive the inactivated shot.”

Opel, et al. The Architecture of Provider-Parent Vaccine Discussions at Health Supervision Visits,

• 2014. American Academy of Pediatrics

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BEHAVIOR CHANGE MODELS

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Health Belief Model

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Transtheoretical Model of Change

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MOTIVATIONAL INTERVIEWING

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Motivational interviewing

• Tobacco cessation
• HIV
• Addictions
• Physical activity
• Chronic health conditions

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The SPIRIT

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Compassion

Acceptance

Key Principles

• Express Empathy

– Understand where patient is and convey that to them

• Develop Discrepancy
• Change is motivated by a perceived discrepancy between present

behavior and their goals/values. Discrepancy should be developed in a non-judgmental way

• Roll with Resistance
• Don’t oppose- reframe as momentum toward change
• Support Self Efficacy
• Key element for change

https://wicworks.fns.usda.gov/wicworks//WIC_Learning_Online/support/job_aids/MI.pdf

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Basic MI Processes Engage Focus Evoke Plan

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1) Engage

• Build a relational foundation
• Establish a rapport and build trust
• Establish roles in the relationship
• Promote mutual buy-in

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ACTIVITY: OARS TECHNIQUE + ROLE PLAY

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2) Focusing

• Develop and maintain a strategic focus
• Collaborate on the conversation
• Use more of a following and guiding vs directive

approach

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Elicit – Provide – Elicit

• Elicit what the person already knows and wants

to know

• Provide information in a neutral manner
• Elicit the person’s response to interpretation of

the information

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Simple role-play

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Advice giving Activity: Informing and Advice Giving Role Play

• Sample Issue: Adult male patient does not want

to get a flu vaccine

• Sample Issue: New parents do not think their

infant needs Hepatitis B vaccine Feel free to use a fake storyline and fake data- the goal is to practice how you say what you are saying

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Resistance

• In motivational interviewing philosophy,

resistance is elicited when we try to push clients farther than they are ready to go

• Resistance also occurs when clients have not

been given sufficient opportunity to direct their actions and have simply been given instructions from their providers

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How do we deal with resistance?

Empathy Empowerment

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Question - Answer Premature Focus Confrontation-Denial Expert

TRAPS

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3) Evoking

• Explore patient’s motivation, goals and ideas
• Identify and resolve ambivalence
• Helps patients come up with their own reasons

for making a change

• Identify barriers to change
• Preparation: target dates, supports, resources

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ACTIVITY: EVOKING SCRIPT

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4) Planning

• Develop a commitment to change
• Focus on the “how”
• Collaborate on incremental goals
• Include adequate structure, accountability and

benchmarks

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9/26/2016 21 ACTIVITY: CHANGE PLAN WORKSHEET

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Final thoughts…

• It is a patient-centered philosophy
• A non-judgmental tone and attitude helps clients

be more open about their “pros” and “cons”

• Focus on the stage the client is at – e.g., don’t

address confidence issues if the client is not yet interested in changing their behavior

• We should dismantle the assumption that we

have failed if clients don’t make decisions toward change at each visit

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Resources

• https://www.aap.org/en-us/advocacy-and-policy/aap-health-

initiatives/immunization/Pages/vaccine-hesitant- parents.aspx?nfstatus=401&nftoken=00000000-0000-0000-0000- 000000000000&nfstatusdescription=ERROR%3a+No+local+token

• Tamma, Pranita D, Cosgrove, Sara E. Addressing the Appropriateness of Outpatient

Antibiotic Prescribing in the United States: An Important First Step. JAMA. 2016;315(17):1839-1841.

• Shapiro DJ, Hicks LA, Pavia AT, Hersh AL. Antibiotic prescribing for adults in

ambulatory care in the USA, 2007–09. J Antimicrob Chemother. 2014;69(1):234-40

• Suda KJ, Hicks LA, Roberts RM, Hunkler RJ, Danziger LH. A national evaluation of

antibiotic expenditures by healthcare setting in the United States, 2009. J

• http://www.cdc.gov/drugresistance/cdc_role.html#tracking_cdcroles
• Opel, et al. The Architecture of Provider-Parent Vaccine Discussions at Health

Supervision Visits, 2014 http://pediatrics.aappublications.org/content/early/2013/10/30/peds.2013-2037..info

• Gust, et al. American Journal of Health Behavior, 2005

http://www.ncbi.nlm.nih.gov/pubmed/15604052#sthash.TRm8qr3T.dpuf

• http://www.state.gov/m/a/os/65759.htm
• http://www.judyringer.com/pdf/free_articles/checklist.pdf
• https://wicworks.fns.usda.gov/wicworks//WIC_Learning_Online/support/job_aids/MI.pdf

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9/26/2016 22 THANK YOU!

Questions or Comments? Please leave your evaluation on the table.

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