MOTIVATIONAL INTERVIEWING: WORKING WITH DIFFICULT PATIENTS/STAFF THURSDAY, SEPTEMBER 28, PM CST

Size: px

Start display at page:

Download "MOTIVATIONAL INTERVIEWING: WORKING WITH DIFFICULT PATIENTS/STAFF THURSDAY, SEPTEMBER 28, PM CST"

Nigel Sherman
5 years ago
Views:

1 MOTIVATIONAL INTERVIEWING: WORKING WITH DIFFICULT PATIENTS/STAFF THURSDAY, SEPTEMBER 28, PM CST

2 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

3 DISCLOSURES Disclosures: Requirements for successful completion CEU certificates after October 15, 2017 (Social Workers only) Conflicts of Interest None Commercial Support None Joint Providers None

4 DEFINITION OF MOTIVATIONAL INTERVENTIONS Designed to enhance motivation for change (in both the employee and the patient)

5 CHARACTERISTICS OF MOTIVATIONAL INTERVENTIONS Brief Responsive Culturally Competent Sensitive to diagnosis Can be used in multiple settings Can be used in various approaches

6 THE FRAMES APPROACH Feedback Responsibility Advice Menus (Options) Empathic Behaviors Self-efficacy

7 After an assessment, the employee or patient gets information regarding personal risk or impairment. FEEDBACK

8 PATIENT EXAMPLES Labs Examples Kidney Disease Quality of Life (KDQOL) Physical Health Nutrition Mental Health Past Patterns of Behaviors

9 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.

10 Date and time of Note: 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.

11 EMPLOYEE EXAMPLES Examples Personality Test Urine Drug Screen (UDS) Survey Scores Physical Health Nutrition Mental Health

12 FEEDBACK Dos Listen Be respectful Use easy to understand language Culturally sensitive Use visual aids Be empathic Offer straightforward information Honest Based on assessment Judgement Don ts Can lead to resistance Use Confrontation At least initially Use the same way with each employee/patient

13 RESPONSIBILIT Y 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

14 Date and time of Note: 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 postagepaid envelope.

15 Date and time of Note: 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.

16 RESPONSIBILIT Y

17 ADVICE Giving information gently and respectfully If done correctly: Can promote positive behavior change Can be effective This is not a parent-child relationship

Advice should be simple and not overwhelming.

18 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

19 Can I tell you what I have seen in the past in this situation? Do you mind if we talk about what happened Monday? Can I tell you something to your about non-compliance? These questions can provide a non-directive opportunity to share your knowledge about non-adherence gently and respectfully.

20 Date and time of Note: 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).

21 Date and time of Note: 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.

22 Date and time of Note: 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.

23 MENUS 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.

24 Date and time of Note: 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.

25 Date and time of Note: 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.

26 EMPATHIC COUNSELING 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

27 SELF-EFFICACY 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.

28 How did you get from where you were to where you are now? You are really doing well.. Identifying strengths

29 Date and time of Note: 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.

30 Date and time of Note: 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.

31 BEING REALISTIC ABOUT CHANGE REALIT Y Does not happen overnight There will be occasional setbacks Learning Experiences NON-REALISTIC Change must occur now Setback means failure

32 PATIENT ADVISORY COMMITTEE (PAC) RECOMMENDATIONS ASKING PERMISSION Do you mind if we talk about what happened Monday? EVOKING, CHANGE TALK What would you like to see dif ferent about your current situation? What makes you think you need to change? Is there a reason for this change? Why do you want to c hange your c hair time? What will happen if you don t change? What will be dif ferent if you complete treatment in 2 days instead of 3? What would be the good things about changing you re[insert risky/problem behavior]? What would your life be like three years from now if you changed your [inser t risky/problem behavior ]? Why do you think others are concerned about your [inser t risky/problem behavior]?

33 PATIENT ADVISORY COMMITTEE (PAC) RECOMMENDATIONS EVOKING CHANGE TALK /DIFFICULT Y 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?

34 PATIENT ADVISORY COMMITTEE (PAC) 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?

35 WEBINAR SERIES UPDATE This webinar is the last webinar in the six-part series Webinars well attended Registered vs. Attendance for Webinars % 50% % 30% 20% 20 10% 0 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 0% Registered % attended

36 # of Web Participants ONLY 18 Webinar Attendance by Organization MI: INTRO HELPFUL LTFU DRY WT IVD DIFFICULT

37 FEEDBACK FROM WEBINAR PARTICIPANTS : PRE-REGISTRATION 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?

38 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 skills for dealing with anxiety) Vocational rehabilitation

ADDRESSING FEEDBACK REQUEST Many of the requests completed by sending out fax blasts to all dialysis facilities in the state of Texas or e -mailing all registrants

39 ADDRESSING FEEDBACK REQUEST 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 ( list serve). Some requests accomplished during webinars. The Network will use the newly created list serve to address incomplete requests.

40 EVALUATION LINK Rechelle Brown, LMSW EVALUATION LINK

41 REFERENCES Barlow J, Wright C, Sheasby J, Turner A, Hainsworth J. Self - management approaches for people with chronic illness: A review. Patient Education and Counseling. 2002;48(2): Bodenheimer, T. et. al. Innovations in Primary Care 2002; 288 (19); Haynes RB. Determinants of compliance: The disease and the mechanics of treatment. Baltimore MD, Johns Hopkins University Press, Lorig K, Holman H. Self-management education: History, definition, outcome and mechanisms. Annals of Behavioral Medicine. 2003;26(1):1 7.

42 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, Miller, W.R. Motivational interviewing with problem drinkers. Behavioral Psychotherapy 11: , Miller, W.R. Motivation for treatment: A review with special emphasis on alcoholism. Psychological Bulletin 15698(1):84 107, 1985b.

43 REFERENCES 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, pp Miller, W.R. What is a relapse? Fifty ways to leave the wagon. Addiction 91(Suppl.):S15 S27, 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, pp

44 REFRENCES 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: , 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): , 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

45 REFERENCES 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, pp 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: , Miller, W.R., and Heather, N., eds. Treating Addictive Behaviors, 2nd ed. New York: Plenum Press, 1998.

46 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: , 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): , 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.

47 REFERENCES Miller, W.R., and Page, A.C. Warm turkey: Other routes to abstinence. Journal of Substance Abuse Treatment 8: , Miller, W.R., and Pechacek, T.F. New roads: Assessing and treating psychological dependence. Journal of Substance Abuse Treatment 4:73 77, Miller, W.R., and Rollnick, S. Motivational Interviewing: Preparing People To Change Addictive Behavior. New York: Guilford Press, 1991.

48 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, 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, pp

49 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, pp 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: , 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.

50 REFERENCES Miller, W.R.; Taylor, C.A.; and West, J.C. Focused versus broad spectrum behavior therapy for problem drinkers. Journal of Consulting and Clinical Psychology 48: , 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, 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: Effective Alternatives, 2nd ed. Boston: Allyn &Bacon, 1995b. pp Miller, W.R.; Zweben, A.; DiClemente, C.C.; and Rychtarik, R.G. Motivational Enhancement Therapy Manual: A Clinical Research Guide for Therapists Treating Individuals With Alcohol Abuse and Dependence. Project MATCH Monograph Series, Vol. 2. NIH Pub. No Rockville, MD: National Institute on Alcohol Abuse and Alcoholism, 1995c.

51 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: Riegel B, Dickson VV. A situation-specific theory of heart failure self-care. Journal of Cardiovascular Nursing. 2008;23(3):

52 REFERENCES Sabate E.WHO Adherence Meeting Report. Geneva,World Health Organization, Schulman-Green D, Jaser S, Martin F, et al. Processes of Self - Management in Chronic Illness, J Nurs Scholarsh. 2012;44:

INVOLUNTARY DISCHARGE (IVD) PROCESS THURSDAY, AUGUST 24, PM CST

INVOLUNTARY DISCHARGE (IVD) PROCESS THURSDAY, AUGUST 24, 2017 2-3 PM CST LEARNING OBJECTIVES To provide direction to dialysis facility practitioners on how to complete Involuntary Discharge (IVD) Paperwork