Motivate change: Use a few key questions

Simple technique good for busy settings

How do you get patients to put into practice the steps for better disease management, prevention techniques, or adherence to a medication regimen?

Try motivational interviewing (MI), advises Steven Cole, MD, professor of psychiatry at Stony Brook (NY) University Medical Center and president and CEO of Comprehensive Motivational Interventions, a trademarked application of MI based in Stony Brook.

While education improves patients' knowledge and skills, it does not necessarily move them into effective behavior change, Cole explains. MI addresses behavior change. Cole describes MI as: "a collaborative, goal-oriented method of communication with particular attention to the language of change. It is designed to strengthen an individual's motivation for and movement toward a specific goal by eliciting and exploring the person's own arguments for change."

This intervention technique was developed by William R. Miller, PhD, an emeritus distinguished professor of psychology and psychiatry at the University of New Mexico in Albuquerque, and Stephen Rollnick, PhD, professor of Health Care Communication in the Department of General Practice, Cardiff University in Wales. Cole developed a particular application of motivational interviewing called Comprehensive Motivational Interventions. He and three colleagues give workshops on these interventions and are developing an e-learning platform.

One motivational tool, called Brief Action Planning (BAP), is designed to be used by clinicians in a busy facility. BAP is organized around three core questions:

  • Is there anything you would like to do for your health in the next week or two (what, when, where, how often, etc.)?
  • On a 0-10 scale of confidence, where 0 means no confidence and 10 means a lot of confidence, about how confident are you that you will be able to carry out your plan? (If confidence is less than 7, initiate collaborative problem-solving.)
  • When would you like to meet again to review how you've been able to do with your plan?

According to Cole, BAP is a short way to begin making a specific and concrete action plan for health. The tool has improved the way she educates patients, says Christine Stamatos, RNP, MSN, a rheumatology nurse practitioner working at L.I. regional Arthritis and Osteoporosis Care in Babylon, NY. "I have always tailored my education to readiness to learn, but this whole process is more collaborative and invites the patient to participate at a greater level," says Stamatos. She is working on her doctoral degree, and Stamatos' advisor suggested she attend a class on BAP presented by Cole. It is designed to be used in an acute setting.

In her practice, she sees 20 to 30 patients a day with about 15 minutes allotted per patient. The patients she sees have complicated disease issues and suffer from such chronic ailments as osteoarthritis, rheumatoid arthritis, fibromyalgia, osteoporosis, and lupus. Stamatos says she performs a significant amount of one-on-one patient education.

Practicing BAP

Putting BAP into practice requires a significant number of open-ended questions, Stamatos says.

She says it is easy to learn, but she is in the process of perfecting it. When patients are on a set of medications and she is monitoring them, it is not hard to ask what they would like to do for their health. When the visit is complicated, for example, she is prescribing several new medications, it is more difficult to find time to ask the basic questions and create an action plan.

Because Stamatos sees her patients on a regular basis, any time from every two weeks to every three months, she can set measurable, concrete goals with patients and see if they achieved them.

One patient with bad osteoarthritis in her knees needed some exercise to feel better. The patient came up with a plan to walk 10 minutes a day for five days a week. Her confidence was at 7 on the scale. Four weeks in a row, she made slight changes in her plan until she was walking 30 minutes a day for five days a week. At the end of that time, her depression, energy, aches, and pains were dramatically improved.

"I think the most important factor that is different is that it is more collaborative. Though I always thought I was good at assessing exactly where someone was and what their needs were, I think I am probably getting better," says Stamatos.

According to Cole, there are three elements in the attitudinal approach, or spirit of motivational interviewing. The first is collaboration between the provider and the patient as equals. The second is evocation, or eliciting ideas for change from the patient. The third element is respect for autonomy, which is communicating clearly that the patient has the right to change or not to change, explains Cole.

Sources

For more information about Brief Action Planning (BAP) and how to implement it, contact:

  • Steven Cole, MD, Professor of Psychiatry, Stony Brook University Medical Center, President and CEO, Comprehensive Motivational Interventions, Stony Brook, NY. Telephone: (631) 757-9720. E-mail: stevencolemd@aol.com. Web: www.ComprehensiveMI.com and stevencolemd.com.
  • Christine Stamatos, RNP, MSN, Rheumatology Nurse Practitioner, L.I. Regional Arthritis and Osteoporosis Care in Babylon, NY. E-mail: castamatos@earthlink.net.