motivational interviewing: working with difficult patients ... 9 27.pdf · motivational...

MOTIVATIONAL

INTERVIEWING: WORKING

WITH DIFFICULT

PATIENTS/STAFF

THURSDAY, SEPTEMBER 28, 2017

2-3 PM CST

LEARNING OBJECTIVES

To provide direction to dialysis facility

practitioners on how to work with difficult patients

and staff members.

Definition of Motivational Interventions

Characteristics of Motivational Interventions

FRAMES Approach

Documentation Examples for Patients

Patient Advisory Committee (PAC) Recommendations

Webinar Series Updates

Evaluation Link

Disclosures:

Requirements for successful completion

CEU certificates after October 15, 2017 (Social Workers

only)

Conflicts of Interest

None

Commercial Support

None

Joint Providers

None

DISCLOSURES

Designed to enhance

motivation for change

(in both the employee and

the patient)

DEFINITION OF MOTIVATIONAL

INTERVENTIONS

Brief

Responsive

Culturally Competent

Sensitive to diagnosis

Can be used in multiple settings

Can be used in various approaches

CHARACTERISTICS OF MOTIVATIONAL

INTERVENTIONS

Feedback

Responsibility

Advice

Menus (Options)

Empathic Behaviors

Self-efficacy

THE FRAMES APPROACH

After an assessment,

the employee or

patient gets

information regarding

personal risk or

impairment.

FEEDBACK

Examples

Labs

Kidney Disease Quality

of Life (KDQOL)

Physical Health

Nutrition

Mental Health

Past Patterns of

Behaviors

PATIENT EXAMPLES

Date and time of Note:

There was a slight increase in patient’s potassium to

5.7. The patient was seen eating a large bag of Lay’s

potato chips on Interdisciplinary Team (IDT) rounds.

He was reminded that those potato chips are from

potatoes which are high in potassium. Also informed

the patient that salty foods might make him thirstier.

A low potassium diet was encouraged. Pt verbalized

understanding of this. Also, the patient reports

forgetting his [specific name] binders again but does

not indicate a better understanding of how he is

supposed to take them.


Staff called patient several times on his cell and his wife’s cell

phone to see if he was available to come for rescheduled

treatment. No response from either. When patient and wife

showed up in the lobby, the nurse told the patient that no reply

was received regarding treatment. The nurse then explained

the importance of clarifying the treatment time before arriving

to avoid other patients being rescheduled for the same chair.

The patient became agitated and stated, “whenever we call

back, you always say there is no chair available, and blame it

on us.” The nurse calmly explained that the intention of their

conversation was not to blame anyone, but to clarify the chair

time to make sure that the chair is available when the patient

comes in for treatment. The patient was given the available

time of 16:00 for treatment. Patient and wife voiced

understanding. Notified clinic manager (CM) of the situation.

Examples

Personality Test

Urine Drug Screen

(UDS)

Survey Scores

Physical Health

Nutrition

Mental Health

EMPLOYEE EXAMPLES

Dos

Listen

Be respectful

Use easy to understand language Culturally sensitive

Use visual aids

Be empathic

Offer straightforward information Honest

Based on assessment

Don’ts

Judgement

Can lead to resistance

Use Confrontation

At least initially

Use the same “way”

with each

employee/patient

FEEDBACK

Change is placed clearly on the employee or patient.

Keeping in mind that the employee or patient has the right to make

their own choices.

Employees or patients to be active, rather than passive, by insisting that

they take responsibility for changing.

Employees or patients can feel more empowered and invested in change

when realizing that they are responsible for the change process.

KEYWORDS:

Choice

Invite

Consider

Inform

RESPONSIBILITY


Social Worker (SW) made the patient aware of the survey

that will be mailed to his house from Centers for Medicare

& Medicaid Services (CMS). The patient was encouraged

to complete the questionnaire and return in the postage-

paid envelope.


The patient came in for treatment. Staff had difficulty

sticking venous. Pt refused to have other staff stick him.

Pt opted to go and said he would be here tomorrow.

RESPONSIBILITY

Giving information gently and respectfully

If done correctly:

Can promote positive behavior change

Can be effective

This is not a parent-child

relationship

ADVICE

It is better not to tell employees or patients what to do.

Research shows that “suggesting” yields better results/outcomes.

Advice should be simple and not overwhelming.

Advice based on facts

Blood Alcohol Level (Blood Alcohol Concentration, BAC)

Laboratory Results

Employee Timesheet

Attendance

ADVICE

These questions can provide a non-directive opportunity to share

your knowledge about non-adherence gently and respectfully.

Can I tell you

what I have seen

in the past in

this situation?

Can I tell you

something to your

about

non-compliance?

Do you mind if we

talk about what

happened

Monday?


The patient was upset that I did not press the button to the

open door in the lobby. I apologized to the patient. The

patient started screaming “mean #@! #@! you just racist,

you just mean!” I asked the patient to calm down, and

stop disrespecting me. The patient continued to scream

“You ain’t nobody, I say what I want. You ain’t #@! to me

and shut the #@!up”. Pt walked out and refused to weigh.

Informed Clinic Manager (CM) and Medical Director (MD).


Social Worker (SW) met with the patient to discuss the

verbal altercation that happened on 7/1/2017 between

patient and nurse. On 7/1/2017 patient used

rude/swearing words when speaking with a nurse. On

7/13/2017, SW and Clinic Manager (CM) met with the

patient to discuss behavioral agreement. During the

meeting, the patient was given rights and responsibilities.


This Social Worker (SW) met with the patient to discuss

events that occurred on XXX. Patient apologized but felt

that his rights were violated. The patient stated that he

was told to go to the bathroom instead of being offered a

urinal. Clinic Manager (CM) joined the meeting and stated

that staff stated that a urinal was provided then moved to

the other side of the chair. The patient stated that he did

not see the urinal on the other side of the chair. This SW

informed the patient that even if he felt his rights were

taken away, he could have responded better. SW informed

the patient that Network 14 was informed that an

additional incident had occurred. This SW also informed

the patient that if further incidents occur, the clinic will

initiate Involuntary Discharge (IVD). Patient educated on

what an IVD entails. The patient reported he would

change his behavior.

Provide a list of options

Accurate information about each option

Patient: Treatment Modalities

Staff: Business of Shifts (MWF vs. TTS)

Employee/Patient must choose an option and take responsibility for their choice

Consistent with motivational interviewing

Informed consent

When a person makes an independent decision, they are much more likely to be committed to that choice.

MENUS


A nurse asked for clarification on patient’s desire to

terminate treatment. The patient became very agitated

and started using profane language at the nurse saying,

“You stop playing with me. #@! you. If you want to play,

play with your husband or kids, or somebody else. You are

a weak lady. You ain’t playing with me. You don’t give me

no respect; you mess with the wrong person.” The nurse

advised the patient not to use such profane language in

front of other patients and staff. The patient went on

saying “Get the #@! out my face. I said get out of my

face.” The nurse walked off and switched places with

Patient Care Technician (PCT) and PCT terminated the

patient's treatment. The patient refused to do the vital

signs that are required for the end care. Clinic Manager

(CM) notified of the situation.


Patient informed social worker that he does not like

coming to treatment in center wants to consider dialysis at

home. The patient voiced concerns that his wife is scared

of needles and would like to consider the option if a nurse

comes to the home for treatment.

Positive Ways

Non-possessive warmth Patient/employee can feel

received in a human way, which is not threatening. In such an atmosphere trust can develop, and the person can feel able to open up to their own experiences and their feelings.

Friendliness

Truthfulness

Respect

Affirmation

Empathy

Person-Centered

Supportive

Reflective Listening

Negative Ways

Opposite of anything Positive

Being irritating

Being too bossy

Negative ways lead to faster client/staff conflicts and have adverse outcomes

EMPATHIC COUNSELING

Fostering Hope

By reinforcing belief in themselves (employees and patients)

You have to like the employee or patient or at least have professional boundaries or awareness of your “dislike” for the employee or patient.

Employee/Patient must choose an option and take responsibility for their choice

Consistent with motivational interviewing

Informed consent

When a person makes an independent decision, they are much more likely to be committed to that choice.

SELF-EFFICACY

Identifying strengths

How did you get

from where you

were to where

you are now?

You are really

doing well…..


Social Worker (SW) met with patient chairside. Patient

reports that he is trying to abide by the contract and

showed this social worker his uncovered access site. This

SW stated that she would make sure to document all

positive encounters, as well, to show the patient is

attempting to make positive changes.


The patient enrolled in Social Work Intensive (SWI). Social

worker will meet with a patient for 6-8 weeks in an

intensive one-on-one basis program due to behavior

toward clinic staff.

REALITY

Does not happen

overnight

There will be occasional

setbacks

Learning Experiences

NON-REALISTIC

Change must occur now

Setback means failure

BEING REALISTIC ABOUT CHANGE

ASKING PERMISSION

Do you mind if we

talk about what

happened Monday?

EVOKING, CHANGE TALK

What would you l ike to see d i f ferent about your cur rent s i tuat ion ?

What makes you th ink you need to change ?

Is there a reason for th is change?

Why do you want to c hange your c hair t ime?

What wi l l happen i f you don’ t change ?

What w i l l be d i f ferent i f you complete t reatment in 2 days instead o f 3?

What would be the good th ings about changing you’ re[ inser t r i sky/problem behav ior ]?

What would your l i fe be l ike three years f rom now i f you changed your [ inser t r i sky/problem behav ior ]?

Why do you th ink others are concerned about your [ inser t r i sky/problem behavior ]?”

PATIENT ADVISORY COMMITTEE (PAC)

RECOMMENDATIONS

EVOKING CHANGE TALK /DIFFICULTY CHANGING

How can I help you with any difficulties you have here at the clinic? (within my control)

What is the BEST thing that could happen if you changed?

If you were to decide to change, what would you have to do differently?

EVOKING CHANGE TALK /PROVOKING EXTREMES

Suppose you don’t change,

what is the WORST thing

that might happen?

What is your attitude about

dialysis?


RECOMMENDATIONS

EVOKING CHANGE TALK /LOOKING FORWARD

If you make changes,

how would your life

be different from

what it is today?

Where do you see

yourself in 2 years?

CONFRONTATION

What are the options you

have for life if you don't

take dialysis?


RECOMMENDATIONS

This webinar is the last webinar in the six-part series

Webinars well attended

WEBINAR SERIES UPDATE

44 41

78

59

99

120

0%

10%

20%

30%

40%

50%

60%

0

20

40

60

80

100

120

140

MI-Intro Helpful Resources Lost to Follow Up vs.

Withdrawal from Care

MI: Treatment times

and Dry Weights

How to Complete IVD

Paperwork

MI: Working with

Difficult Patient/Staff

Registered vs. Attendance for Webinars

Registered % attended

0

2

4

6

8

10

12

14

16

18#

of

We

b P

art

icip

an

ts O

NLY

Webinar Attendance by Organization

MI: INTRO

HELPFUL

LTFU

DRY WT

IVD

DIFFICULT

• Bed bugs

• Behavioral agreements

• Compliance

• Cultural sensitivity

• Emergency preparedness requirements final rule

• Ethics Continuing Education Units (CEUs)

• Getting patient buy -in to participating in dialysis (not just receiving dialysis services)

• Inappropriate behaviors with staff

• Insurance Coverages

• Integration of assessment and plan of care to include

follow-up

• Intervention on patients refusing access

• Intradialytic Weight Gain (IDWG)

• Intro to Crown Web - Why?

FEEDBACK FROM WEBINAR PARTICIPANTS :

PRE-REGISTRATION

• Mental health and dialysis

• Missed treatments

• More Motivational Interviewing

• Motivational Interviewing on missed treatments

• Patient Care Conference meetings

• Patient engagement survey

• Patient satisfaction

• Patients dealing with loss, careers, and family about end of

life issues

• Refreshers on modality options

• Resolving patient and staff conflict

• Self-care for the helping professional (most requested)

• Short mental health interventions for patients (coping skil ls for dealing with anxiety)

• Vocational rehabilitation

FEEDBACK FROM WEBINAR PARTICIPANTS :

PRE-REGISTRATION

Many of the requests completed by sending out fax blasts to all

dialysis facilities in the state of Texas or e -mailing all

registrants information (e -mail l ist serve). Some requests

accomplished during webinars. The Network will use the newly

created e-mail l ist serve to address incomplete requests.

ADDRESSING FEEDBACK REQUEST

Rechelle Brown, LMSW

[email protected]

469-916-3808

EVALUATION LINK

https://www.surveymonkey.com/r/M8GGLHK

EVALUATION LINK

mailto:[email protected]

https://www.surveymonkey.com/r/M8GGLHK

REFERENCES

Barlow J, Wright C, Sheasby J, Turner A, Hainsworth J. Self -

management approaches for people with chronic il lness: A

review. Patient Education and Counseling. 2002;48(2):177 –187

Bodenheimer, T. et. al. Innovations in Primary Care 2002; 288

(19); 2469-2474.

Haynes RB. Determinants of compliance: The disease and the

mechanics of treatment. Baltimore MD, Johns Hopkins

University Press, 1979.

Lorig K, Holman H. Self -management education: History,

definition, outcome and mechanisms. Annals of Behavioral

Medicine. 2003;26(1):1–7.

REFERENCES

Miller, L. Neuropsychological assessment of substance abusers: Review and recommendations. Journal of

Substance Abuse Treatment 2(1):5−17, 1985a.

Miller, W.R. Alcoholism scales and objective assessment methods: A review. Psychological Bulletin 98:84−107,

1976.

Miller, W.R. Motivational interviewing with problem drinkers. Behavioral Psychotherapy 11:147−172, 1983.

Miller, W.R. Motivation for treatment: A review with special emphasis on alcoholism. Psychological Bulletin

15698(1):84−107, 1985b.

Miller, W.R. Increasing motivation for change. In: Hester, R.K.,

and Miller, W.R., eds. Handbook of Alcoholism Treatment

Approaches: Effective Alternatives, 2nd ed. Boston: Allyn

&Bacon, 1995. pp. 89−104.

Miller, W.R. What is a relapse? Fifty ways to leave the wagon.

Addiction 91(Suppl.):S15−S27, 1996.

Miller, W.R.; Andrews, N.R.; Wilbourne, P.; and Bennett, M.E. A

wealth of alternatives: Effective treatments for alcohol

problems. In: Miller, W.R., and Heather, N., eds. Treating

Addictive Behaviors: Processes of Change, 2nd ed. New York:

Plenum Press, 1998. pp. 203−216.

REFERENCES

Miller, W.R., and Baca, L.M. Two−year follow−up of bibliotherapy and therapist−directed controlled drinking training for problem drinkers. Behavior Therapy 14:441−448, 1983.

Miller, W.R.; Benefield, R.G.; and Tonigan, J.S. Enhancing motivation for change in problem drinking: A controlled comparison of two therapist styles. Journal of Consulting and Clinical Psychology 61(3):455−461, 1993.

Miller, W.R.; Brown, J.M.; Simpson, T.L.; Handmaker, N.S.; Bien, T.H.; Luckie, L.F.; Montgomery, H.A.; Hester, R.K.; and Tonigan, J.S. What works? A methodological analysis of the alcohol treatment outcome literature. In: Hester, R.K., and Miller, W.R., eds. Handbook of Alcoholism Treatment Approaches: Effective Alternatives, 2nd ed. Boston: Allyn &Bacon, 1995a.

pp . 12−44.

REFRENCES

Miller, W.R., and C'de Baca, J. Quantum change: Toward a

psychology of transformation. In: Heatherton, T., and

Weinberger, J., eds. Can Personality Change? Washington, DC:

American Psychological Association, 1994. pp. 253−280

Miller, W.R.; Gribskov, C.J.; and Mortell, R.L Effectiveness of a

self−control manual for problem drinkers with and without

therapist contact. International Journal of the Addictions

16:1247−1254, 1981.

Miller, W.R., and Heather, N., eds. Treating Addictive Behaviors,

2nd ed. New York: Plenum Press, 1998.

REFERENCES

Miller, W.R., and Kurtz, E. Models of alcoholism used in

treatment: Contrasting AA and other perspectives with which it

is often confused. Journal of Studies on Alcohol 55:159−166,

1994.

Miller, W.R.; Leckman, A.L; Delaney, H.D.; and Tinkcom, M.

Long−term follow−up of behavioral self−control training.

Journal of Studies on Alcohol 53(3):249−261, 1992.

Miller, W.R., and Meyers, R.J. Engaging unmotivated individuals

in treatment for alcohol problems: A comparison of three

intervention strategies. Journal of Consulting and Clinical

Psychology, in press.

REFERENCES

Miller, W.R., and Page, A.C. Warm turkey: Other routes to

abstinence. Journal of Substance Abuse Treatment 8:227−232,

1991.

Miller, W.R., and Pechacek, T.F. New roads: Assessing and

treating psychological dependence. Journal of Substance Abuse

Treatment 4:73−77, 1987.

Miller, W.R., and Rollnick, S. Motivational Interviewing:

Preparing People To Change Addictive Behavior . New York:

Guilford Press, 1991.

REFERENCES

Miller, W.R., and Sanchez, V.C. Motivating young adults for

treatment and lifestyle change. In: Howard, G., and Nathan,

P.E., eds. Alcohol Use and Misuse by Young Adults. Notre Dame,

IN: University of Notre Dame Press, 1994.

Miller, W.R., and Saucedo, C.F. Assessment of

neuropsychological impairment and brain damage in problem

drinkers. In: Golden, C.J.; Moses, J.A., Jr.; Coffman, J.A.; Miller,

W.R.; and Strider, F.D., eds. Clinical Neuropsychology: Interface

With Neurologic and Psychiatric Disorders. New York: Grune

&Stratton, 1983. pp. 141−195.

REFERENCES

Miller, W.R., and Sovereign, R.G. The check−up: A model for early intervention in addictive behaviors. In: Loberg, T.; Miller, W.R.; Nathan, P.E.; and Marlatt, G.A., eds. Addictive Behaviors: Prevention and Early Intervention. Amsterdam: Swets &Zeitlinger, 1989. pp. 219−231.

Miller, W.R.; Sovereign, R.G.; and Krege, B. Motivational interviewing with problem drinkers: II . The Drinker's Check−up as a preventive intervention. Behavioral Psychotherapy 16:251−268, 1988.

Miller, W.R., and Taylor, C.A. Relative effectiveness of bibliotherapy, individual and group self−control training in the treatment of Enhancing Motivation for Change in Substance Abuse Treatment problem drinkers. Addictive Behaviors 5:13−24, 1980.

REFERENCES

Miller, W.R.; Taylor, C.A .; and West, J .C. Focused versus broad−spectrum behavior therapy for problem drinkers. Journal of Consulting and Cl inical Psychology 48:590−601, 1980.

Miller, W.R., and Tonigan, J .S. Assessing drinkers' motivation for change: The Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES). Psychology of Addictive Behaviors 10(2):81−89, 1996.

Miller, W.R.; Westerberg, V.S. ; and Waldron, H.B. Evaluating alcohol problems. In: Hester, R.K., and Miller, W.R., eds. Handbook of Alcoholism Treatment Approaches: Ef fective Alternatives, 2nd ed. Boston: Al lyn &Bacon, 1995b. pp. 61−88.

Miller, W.R.; Zweben, A . ; DiClemente, C.C. ; and Rychtarik , R.G. Motivational Enhancement Therapy Manual: A Cl inical Research Guide for Therapists Treating Individuals With Alcohol Abuse and Dependence. Project MATCH Monograph Series, Vol . 2. NIH Pub. No. 94−3723. Rockvil le, MD: National Institute on Alcohol Abuse and Alcoholism, 1995c.

REFERENCES

Rand CS. Measuring adherence with therapy for chronic

diseases: implications for the treatment of heterozygous

familial hypercholesterolemia. American Journal of

Cardiology,1993, 72:68D-74D.

Richard AA, Shea K. Delineation of self -care and associated

concepts. Journal of Nursing Scholarship. 2011;43:255–264

Riegel B, Dickson VV. A situation -specific theory of heart failure

self-care. Journal of Cardiovascular Nursing. 2008;23(3):190–

196.

REFERENCES

Sabate E.WHO Adherence Meeting Report. Geneva,World Health

Organization, 2001.

Schulman-Green D, Jaser S, Martin F, et al. Processes of Self -

Management in Chronic Illness, J Nurs Scholarsh . 2012;44:136-

144

REFERENCES

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