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

Tamara S wigert, MS N, RN, CDE November 10, 2017 tamara.swigert@ gmail.com

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

 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...

Mrs. Garcia is a 58-year old Hispanic f emale wit h t ype 2 diabet es who is... Afraid of Unsure of how t o short / long-t erm Unable t o afford t ake her t he medicat ion effect s of medicat ion t reat ment Confused by t he Unaware of Unable t o complicat ed seriousness of t olerat e t he side t reat ment not t aking (in effect s of regimen denial) medicat ion Resist ant t o t x Feeling plan due t o Afraid of what overwhelmed or cult ural/ spirit ual ot hers will t hink depressed beliefs

• • Implies a passive role, Implies an active role, in following demands of collaboration with prescriber prescriber • Clinician-patient collaboration • Clinician dominance • Goal: patient self-mastery • Goal: obedience to • Activities are negotiated, plan clinician/ staff orders matched to lifestyle of patient • Activities are dictated; pts • S elf-motivated decision to told what they must do and stick to treatment advice lectured when they do not • S elf-regulation of illness & • Noncompliers are j udged as treatment deviant, incompetent, lazy, • Resistance provides or stubborn information for adaptation • Resistance is discouraged • Tools: discussion, motivation, • Tools: persuasion, coercion negotiation Gould, E. (2010). P. 291

S okol et al. Med Care (2005) * P< 0.05 when compared to the 80-100% group

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 Behavioral Behavior S kills Change Motivation World Health Organization (2003)

Technique Example Ordering Y ou 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 ou don’t want t o do t hat . Dismissiveness Y ou 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 ou 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 our 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 o 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 only takes it when he eats a big meal. 1. Cost 2. S tigma 3. Fear of medication effect 4. Regimen too complicated

Readiness to Change is a measure of . . . ● IMPORTANCE (“I want to”), AND … ● CONFIDENCE (“I believe I can”)  “ 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 Case Management Adherence Guidelines (2006)

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