Having Difficult Conversations: Working through Conflict and - PDF document

9/26/2016 Having Difficult Conversations: Working through Conflict and Uncertainty with Motivational Interviewing Presented by: Alison Dent, Immunize Oregon Coordinator Alyssa McClean, Oregon AWARE Coordinator Agenda • Introductions • Controversy in Oregon – Antibiotic resistance – Vaccine hesitancy • Difficult conversations – Realities – Principles – Techniques • Behavior Change Models • Motivational interviewing – Basics – Demonstration 2 3 1

9/26/2016 4 5 Oregon AWARE ANTIBIOTIC RESISTANCE 6 2

9/26/2016 http://www.cdc.gov/getsmart/community/images/materials/ar-deaths.jpg 7 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 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 8 For the spending in outpatient settings: Suda KJ, Hicks LA, Roberts RM, Hunkler RJ, Danziger LH. A national evaluation of 8 antibiotic expenditures by healthcare setting in the United States, 2009. J Proportion of patients filling antibiotic prescriptions, by age group, Oregon, 2013 9 3

9/26/2016 Broad vs. narrow spectrum antibiotic use among patients filling antibiotic prescriptions, Oregon, 2013 10 Proportion of patients filling antibiotic prescriptions vs proportion needing antibiotics, Oregon, 2013 80 68 70 65 62 60 49 50 Percent 40 40 28 30 25 20 11 10 10 5 0 Acute Otitis Sinusitis Pharyngitis Bronchitis Common Cold Media Received Antibiotic Likely Needed Antibiotic 11 Immunize Oregon VACCINE HESITANCY 12 4

9/26/2016 Categorization of Attitudes Toward Vaccines Gust, et al. American Journal of Health Behavior, 2005 http://www.ncbi.nlm.nih.gov/pubmed/15604052#sthash.TRm8qr3T.dpuf 13 14 5

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9/26/2016 28 29 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Bill 895 (2015-2016) Key changes made by Senate Bill 895 • Religious exemptions signed prior to March 1, 2014, are no longer valid.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. 30 10

9/26/2016 https://public.health.oregon.gov/PreventionWellness/VaccinesImmunization/G ettingImmunized/Pages/SchResources.aspx 31 Realities, principles, techniques DIFFICULT CONVERSATIONS 32 “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 33 11

9/26/2016 Human nature • Bring negative assumptions into the conversation • Spend “listening” time crafting rebuttals • Don’t address core issues 34 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 35 Realities of time • Short patient interactions 36 12

9/26/2016 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 37 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 38 BEHAVIOR CHANGE MODELS 39 13

9/26/2016 Health Belief Model 40 Transtheoretical Model of Change 41 MOTIVATIONAL INTERVIEWING 42 14

9/26/2016 43 Motivational interviewing • Tobacco cessation • HIV • Addictions • Physical activity • Chronic health conditions 44 45 15

9/26/2016 The SPIRIT Compassion Acceptance 46 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 47 Basic MI Processes Plan Evoke Focus Engage 48 16

9/26/2016 1) Engage • Build a relational foundation • Establish a rapport and build trust • Establish roles in the relationship • Promote mutual buy-in 49 ACTIVITY: OARS TECHNIQUE + ROLE PLAY 50 2) Focusing • Develop and maintain a strategic focus • Collaborate on the conversation • Use more of a following and guiding vs directive approach 51 17

9/26/2016 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 52 Simple role-play Advice giving 53 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 54 18

9/26/2016 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 55 How do we deal with resistance? Empathy Empowerment 56 Question - Answer TRAPS Premature Focus Confrontation-Denial Expert 57 19

9/26/2016 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 58 ACTIVITY: EVOKING SCRIPT 59 4) Planning • Develop a commitment to change • Focus on the “how” • Collaborate on incremental goals • Include adequate structure, accountability and benchmarks 60 20

9/26/2016 ACTIVITY: CHANGE PLAN WORKSHEET 61 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 62 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 63 21

9/26/2016 Questions or Comments? Please leave your evaluation on the table. THANK YOU! 64 22