Tamara S wigert, MS N, RN, CDE November 10, 2017 tamara.swigert@ - - PowerPoint PPT Presentation

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Tamara S wigert, MS N, RN, CDE

November 10, 2017

Review possible causes of patient non-adherence List examples of effective and ineffective communication techniques specific to patient encounters Describe key concepts and skills of effective motivational interviewing and goal setting Apply effective communication and Motivational Interviewing principles in patient encounters

After participating in this learning activity, the participant will be able to …

 The failure or refusal t o comply: t he failure or

refusal t o conform and adapt one's act ions t o a rule or t o necessit y.

Medicinenet : http:/ / www.medicinenet.com/ script/ main/ hp.asp

• Compliance is associated with the medical model
• Connotes a 1-way relationship (provider/nurse tells

patient what to do)

• Suggests a judgment on the patient, “does not do

what he/she is told”

• Leads to frustration on the part of health care staff

 IDC-10 codes Z91.19: Noncompliance section

(includes specifics such as: financial hardship, dietary, underdosing, intentional versus unintentional, etc.)

 We have all done it! But who does it help

and where do we go from there?

 Usually situation is more complicated (we

need to look deeper)

 Why do we do it?

RN report example: Mrs. Garcia is a 58-year old Hispanic female who is a noncompliant t ype 2 diabet ic...

Unsure of how t o t ake her medicat ion Unable t o afford t he medicat ion Afraid of short / long-t erm effect s of t reat ment Confused by t he complicat ed t reat ment regimen Unaware of seriousness of not t aking (in denial) Unable t o t olerat e t he side effect s of medicat ion Feeling

• verwhelmed or

depressed Resist ant t o t x plan due t o cult ural/ spirit ual beliefs Afraid of what

• t hers will t hink
• Mrs. Garcia is a 58-year old Hispanic f emale

wit h t ype 2 diabet es who is...

• Implies a passive role,

following demands of prescriber

• Clinician dominance
• Goal: obedience to

clinician/ staff orders

• Activities are dictated; pts

told what they must do and lectured when they do not

• Noncompliers are j udged as

deviant, incompetent, lazy,

• r stubborn
• Resistance is discouraged
• Tools: persuasion, coercion
• Implies an active role, in

collaboration with prescriber

• Clinician-patient collaboration
• Goal: patient self-mastery
• Activities are negotiated, plan

matched to lifestyle of patient

• S

elf-motivated decision to stick to treatment advice

• S

elf-regulation of illness & treatment

• Resistance provides

information for adaptation

• Tools: discussion, motivation,

negotiation

Gould, E. (2010). P. 291

* P< 0.05 when compared to the 80-100% group

S

• kol et al. Med Care (2005)

Increasing t he ef f ect iveness of adherence int ervent ions may have a f ar great er impact on t he healt h of t he populat ion t han any improvement in specif ic medical t reat ment s.

World Health Organization (2003)

 Communication is PROVIDER/ NURS

E centered, not P ATIENT centered

 We tell patient what he/ she needs  We speak much more than we listen  We talk AT the patient, rather than discussing  We establish clinical goals rather than considering

what is important to patient

 We assume our goals should be patient’s goals  We do not take time to find out how illness (and

treatment) impacts patient

 Resistance to change is seen as a handicap

that we need to bury, vs. explore

 Dictate (“ you need to” ) rather than

negotiate (“ what are you prepared to ...” ) behavior change

 Communication is rushed and one-sided  Prevalent attitude: S

ave the patient rather than patients save themselves

 Patient’s “ readiness to change” is rarely

considered

The World Health Organization has made a strong case that medication adherence is based on three pillars: patient information, motivation, and behavioral skill requirements. Information Motivation Behavior Change Behavioral S kills

World Health Organization (2003)

Technique Example Ordering Y

• u are going t o have t o t est four t imes per day.

Passing j udgment I t hink it is wrong of you not t o bring your husband. Changing subj ect Let ’s not t alk about t he diet issues right now. False Hope Don’t worry, everyt hing will work out fine. Generalizations People always feel bet t er once t hey get used t o exercise. Defensiveness Come on – no one here would int ent ionally lie t o you. Arguing How can you say you’ re doing bet t er when your A1c … Aggressiveness It ’s your own fault t hat you are here in t he hospit al. Proj ecting I know how you feel. OR Y

• u don’t want t o do t hat .

Dismissiveness Y

• u are making a big deal out of not hing.

S arcasm Go ahead and have t he pie; aft er all, who needs feet ?

Technique Example Active Listening Eye contact, relaxed posture Observation Y

• u seem concerned about t he change t o your insulin.

Empathy It must be frust rat ing t o have t o change your rout ine … S haring Hope I have seen many pat ient s who t hought t he same t hing … Humor Can diffuse tense situation, encourage, comfort S ilence Allows time to think; silence will encourage response Provide info. Y

• ur A1c t est result is 8.9%

. The A1c t est s t ells us … Clarifying What do you mean by “ more t hat usual” ? Focusing Let ’s look at what you at e for breakfast t his morning … Paraphrasing S

• it sounds like you are saying you are unsure about …

Active Listening Eye contact, relaxed posture

 Reflect ive List ening

 Listen; avoid interrupting  Paraphrase back what patient has said to show understanding: “ It

sounds like you . . .” or “ What you are saying is . . .”

 Open ended quest ions

 Requires more than a one-word answer  Use “ Tell me . . . “ What . . .” “ How . . .” (avoid “ Why” –

j udgmental)

 Nonverbal communicat ion (post ure, proximit y/ posit ion,

eye cont act , et c.): biggest influence on message delivery

 Words used: 7%  Tone of voice: 38%  Body language: 55%

 Affirmat ion

 Praise client’s efforts; acknowledge strengths  Be genuine; genuine affirmation promotes self-efficacy

Talk to the patient:

 Avoid j udgment  Ask “ What” instead of “ Why”  Ask open ended questions

Look for clues; use deductive reasoning

skills (RNs are great with these)!

Avoid a rush to j udgment (how many

times have we been told by others that a patient has poor health due to their non-compliance? )

• In the following examples, select the most likely

adherence BARRIER the patient may be facing.

• Mrs. Jones faithfully takes insulin and

multiple other medicines during the day as

• prescribed. But every night before bed she

gives only half of the prescribed dose. She lives alone.

• 1. Cost
• 2. Knowledge deficit
• 3. Fear of medication effects
• 4. Regimen too complicated

• In the following examples, select the most likely

adherence BARRIER the patient may be facing.

• Mr. Smith is willing to check glucose in the

morning and before bed. He is open to the idea of mixed insulin BID but not AC/HS. He declines your invitation to participate in group classes.

• 1. Cost
• 2. S

tigma

• 3. Fear of medication effect
• 4. Regimen too complicated

• In the following examples, select the most likely

adherence BARRIER the patient may be facing.

• Mr. Washington takes the full dose of his

generic metformin and glyburide as directed, but cuts his Januvia (non-generic) in half and

• nly takes it when he eats a big meal.
• 1. Cost
• 2. S

tigma

• 3. Fear of medication effect
• 4. Regimen too complicated

 “ On a scale of 0-10, how important is it for you to …

? ”



“ On a scale of 0-10, how confident are you … ? ”

0 1 2 3 4 5 6 7 8 9 10

Readiness to Change is a measure of . . .

• IMPORTANCE (“I want to”), AND …
• CONFIDENCE (“I believe I can”)

Case Management Adherence Guidelines (2006)

Group B Low importance, High Confidence Group D High Importance, High Confidence Group A Low importance, Low confidence Group C High importance, Low confidence

Case Management Adherence Guidelines (2006)

Questions to ask:

 Why a 2 and not a 1?  What makes you t hink t his could be a problem?  What are t he downsides of making a change?  What do you t hink t he result s of change might

be?

Tools & Interaction:

 Find what matters to patient  Link positive health outcomes to what matters  Don’ t tell patient he/ she is “ wrong”  Encourage “ test your theory” (give it a try)

Case Management Adherence Guidelines (2006)

Adherence Intention is VARIABLE Questions to ask:

 What t hings might get in t he way of success?  What can you do t o overcome t hese barriers?  What t ools, skills, knowledge or adj ust ment s do

you need t o make t his work?

Tools & Interaction:

 Break down into small short lessons, repeat  Use demonstration with teach back  Write it down  Teach caregivers/ supporters  Praise patient efforts (build confidence)

Case Management Adherence Guidelines (2006)

 “ A skillful clinical style for eliciting from

patients their own motivation for making changes in the interest of their health”

 Introduced by Miller & Rollnick in the early

1990s (for drug & alcohol addiction)

 S

hown to be successful for behavioral change in many applications (incl. chronic disease)

 AMBIVALENCE and/ or RES

IS TANCE are key

• pportunities to engage

 Focuses on assessing and encouraging the

patient’s motivation to change, NOT motivating the patient

Rollnick, Miller, & Butler, (2007) and Welch, Rose, & Ernst (2006)

 Motivational Interviewing skills are matched

with patient's readiness-to-change stage

 Create a climate that is safe for patient to

share, learn, change OR to challenge, question and rej ect the provider’s suggestions

 Be honest with patients so they can make

an informed choice (do not “ sugar- coat” / soften or exaggerate)

Rollnick, Miller, & Butler, (2007) and Welch, Rose, & Ernst (2006)

 COLLABORATION:

 Partnership with focus on the client (patient)  S

hared decision making between client and provider

 EVOCATIVE:

 Understanding client’s goals  Connecting behavior change with what client values  Use discrepancy between values and current

behavior to evoke reasons for change

 CLIENT AUTONOMY:

 Client ultimately decides what to do  We are inherently resistant to being told what to do  Provider honors patient’s decision (regardless of own

feelings)

 Very tough! We must resist the “ righting reflex”

(urge to fix things)

Rollnick, Miller, & Butler, (2007) and Welch, Rose, & Ernst (2006)

Roll with Resistance Express Empathy Avoid Argumentation Develop Discrepancy S upport S elf-Efficacy

Rollnick, Miller, & Butler, (2007) and Welch, Rose, & Ernst (2006)

 Acknowledge that change is always hard for

multiple reasons.

 Explore why patient may not want to change

current behavior…

 What are t he good point s about doing j ust what

you are doing now?

 Now what are t he downsides of making t his

change?

 Now what are t he downsides of st icking wit h

what you are doing now and t he upsides t o making t he change?

 PT: I don’ t want to take another pill every

• day. Too much medicine isn’ t good for you.

 RN: It sounds like are worried about the

amount of medicine you are on and that more could make things worse. Is that right?

 PT: Right . . . I don’ t want that to happen.  RN: I don’ t blame you! Let’s talk about the

good and bad sides of this medicine. Then you can decide, but at least you will have all the information.

 Listen reflectively.  Paraphrase or summarize what they have

said to show “ you get it”

 Ask open ended questions.  Do not say “ I know how you feel” but rather,

“ I can imagine that it must be … ”

 Allow patient to “ vent” (but not too much)

 PT: Everyone makes it sound like it is no big

deal, but I am freaking out at all this stuff … change what I eat, check my blood, take this insulin, but watch out for low blood sugar …

 RN: I can imagine you must feel very

• verwhelmed. Y
• u have been asked to make a

lot of changes to manage this new diabetes and you are sure that you can do it all. Is that right?

 PT: Y

es, that is exactly right.

 RN: Let’s break this down into some more

manageable chunks. How about if we identify j ust the essentials for now?

 Foster the TEAM approach (not you vs. them)  Do not debate or “ prove wrong”  When correcting, ask permission to share

information.

 Assure patient that it is not your plan to force

them into anything but to give them information so that they can make an informed decision that fits them best.

 Avoid j udgmental language, posture, etc.

(ask “ what” instead of “ why” )

 PT: Insulin is terrible for you! It causes

kidneys to fail and heart attacks. I don’ t want it!

 RN: S

• unds like you have some serious

concerns about the safety of this stuff we want to give you, am I right?

 PT: Y

eah, that’s pretty much it.

 CDE: Well let me tell you, your are not the

• nly one to have those concerns! Can I tell

you some things you might not know about this medicine?

 PT: I guess so.

 This is what helps move the patient from

resistance to action.

 Identify (or help patient recognize) the things

that are important to him/ her (goals, values, dreams, etc.)

 Highlight how current behavior is in conflict

with those items.

 Help patient see the disconnect with

questions that allow patient to draw conclusions … “ How do you think the way your diabetes is now syncs with what you want out of life? ”

 RN: S

• , you were telling me about how you’ d

really like to go to college next year to study

• music. But you also said that you often

forget your insulin and some of the times it makes you feel really sick and end up in the hospital with DKA.

 PT: Y

ea, that’s true.

 RN: S

• what are your thoughts about how this

pattern can affect your goal of going to college next year?

 PT: Well, I guess that if I really want to go …

 While you may be the diabetes expert,

recognize the patient as the expert on his/ her life and values

 Allow patient to suggest next step, plan, goals,

etc.

 Acknowledge that roadblocks are likely to arise.

Let patient know he/ she has support and resources

 Commend progress (even small) and emphasize

that they should feel proud of what has been accomplished.

 Respect the patient’s right to go against

medical recommendations. Resist the “ righting reflex” (this is VER Y tough for those in the healthcare profession)

 PT: I have been thinking more about what you

said about having to give myself shots.

 RN: Great. Tell me what you have come up

with.

 PT: Well, taking insulin shots four times a day

j ust isn’ t going to be possible, but I think I might be able to do once a day.

 RN: S

• unds like a good place to start. How

about if I show you how to do it? Then you can try yourself. In the meantime, let me talk to the doc and see what once daily options might work.

Setting goals are an important aspect of self-care Start with some short term goals Patients may need assistance in setting goals Goals may need to be adjusted from time to time Goals should be patients' goals, not RN/MDs’ Work on as few goals goal at a time as possible Goals should be “S.M.A.R.T.” . . .

Specific

• What do you expect t o have happen?
• Break large goals down int o smaller ones

Measureable

How will you know you are making progress? Use concret e measuring t ools.

Attainable

Is t he goal realist ic wit h your current resources? Aim for a goal t hat will not cause undue st ress.

Relevant

• Is t his goal import ant t o you personally?
• Choose goal t hat will make a real difference.

Time-defined

• How much t ime is scheduled t o work on it ?
• S

et a dat e on which you plan t o complet e goal.

 Allow patient to direct communication; listen more  Turn off the “ fix-it” impulse; facilitate patient in

driver’s seat

 Always consider patient’s readiness to change  Use effective communication techniques

 Reflective listening  Open-ended questions  Non-verbal communication  Affirmation

 Use MI S

kills

 Roll with Resistance  Express Empathy  Avoid Argumentation  Develop Discrepancy  S

upport S elf-efficacy

 Assist patient with setting S

.M.A.R.T . goals

 48 y/ o female, admitted for leg abscess, j ust

diagnosed with type 2 DM while in the hospital.

 A1C is 11.6%

(j ust measured in hospital)

 Discharge Medication regimen: Metformin 1000

mg BID and 12 units Lantus QHS

 When you greet her and ask how she is doing

today, she breaks down into tears. S he states that she is not doing well; she feels like there is no way she can handle all this.

 S

he states that her mother died of diabetes and she does not think she can do this.

 68 y/ o male, hist ory of t ype 2 diabet es (13 years);

admit t ed for acut e renal inj ury; A1c: 9.2%

 When you t alk t o him about his diabet es he t ells you he

checks his blood sugar at home t hree t imes a day and t akes his insulin and pills as direct ed. S t at es his blood sugar is always bet ween 80 and 120.

 He cannot t ell you what his doses are but says he has

t hem writ t en on a paper at home.

 Lat er admit s t hat somet imes he forget s t o check his

blood sugar and t o t ake his insulin because he get s t oo t ired at night and falls asleep in front of t he t elevision.

 To make small t alk, he t ells you about his golf game (he

is proud of his skill and accomplishment s on t he golf course)

 19 y/ o female, history of type 1 diabetes (7 yrs).

Admitted for DKA (third time in 12 months)

 A1C is 13.1%  Mother is there. S

he tells you, “ I am through! It does not matter what I do, she j ust does not care. I tell her over and over what will happen to her if she keeps this up; maybe she will listen to you.”

 Patient does not seem to want to engage. S

eems despondent, even depressed. S he does perk up when her friends come to visit and talk about a concert they are all planning to go to next month.

 Home regimen: Basal/ bolus (MDI) therapy.

Levemir BID and NovoLog TID AC with a carb ratio

• f 8 and correction factor of 40. (no pump/ CGM)



Case Management Adherence Guidelines, version 2.0 (June, 2006). Case Management S

• ciety of America Accessed 7 Feb 2012 from

http:/ / www.cmsa.org/ portals/ 0/ pdf/ CMAG2.pdf



Gould, E. (2010). Medication adherence is a partnership; medication compliance is not. Geriat ric Nursing, 31 (4), 290-298. Morisky DE, Green L W, Levine DM. Med Care. 1986;24:67-74. (find in Case Management Adherence Guidelines, 2006)



Rollnick, Miller, & Butler, (2007). Motivational Interviewing in Healthcare. Guilford Press.



S

• kol et al. (2005). Impact of medication adherence on hospitalization

risk and healthcare cost . Medical Care 43(6), 521-530.



Welch, G., Rose, G., and Ernst, D. (2006). Motivational interviewing and diabetes: What is it, how is it used and does it work? Diabet es S pect rum, 19,1, 5-11. Accessed from http:/ / spectrum.diabetesj ournals.org/ content/ 19/ 1/ 5.full on January 12, 2014.



World Health Organization (2003). Adherence to Long-Term Therapies: Evidence for Action. Accessed 7 May 2012 from http:/ / whqlibdoc.who.int/ publications/ 2003/ 9241545992.pdf