The management of chronic diabetes self-care programs is mainly the responsibility of the patient. In primary care, nurses normally emphasize the prevention of complications and adherence to diabetes self management regimes. However, compliance to diabetes self-care programs is always a challenge for many diabetes patients. Diabetes self-management programs require patients to make many lifestyle and dietary changes. Diabetes patients need to be highly motivated to adopt and conform to the lifestyle changes in diabetes self-care programs (Perry & Collins, 2009). This paper describes the process of implementing a protocol for motivational interviewing for diabetes patients at Ben Taub Hospital in Houston, Texas.
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Different diabetes patients have very different perceptions of self-care, which includes conformation to dietary planning, regular exercise and regular testing of blood sugars. Diabetes patients have very different self-care coping strategies that are influenced by the health value they attach to self-care. These coping strategies affect the way diabetes patients respond to diet and exercise choices, the frequency of the blood glucose monitoring and compliance to diabetes medication (Perry & Collins, 2009).
Nurses should therefore, pay attention to the patients coping strategies and perceptions in helping patients manage their diabetes. Self-care protocols for diabetes patients should be tailor made to suit the coping strategies for patients. In many primary care settings, nurses provide advice and information to encourage diabetes patients embrace positive behavioral changes in diabetes care. However, information and advice alone are not sufficient in encouraging patients to embrace positive lifestyle changes (Perry & Collins, 2009).
One method that primary care nurses can utilize in inspiring diabetes patients to embrace positive lifestyle changes is motivational intervening. Motivational interviewing is a patient-centered method of inspiring a person to embrace change through change talks and interviews. This technique is very successful in helping patients overcome the negative perceptions and thoughts that make them have ambivalence to lifestyle changes (Sobel, 2008).
Motivational interviewing enables nurses match self-care strategies with a patient’s motivation to embrace change. Motivational interviewing is utilized by many health care providers in many health care settings for behavioral change. Motivational interviewing is applied on a continuous basis until a patient overcomes the ambivalence to change (Sobel, 2008).
Motivational interviewing is very effective in helping patients embrace positive behavioral changes compared to other methods like the provision of education and information (Sobel, 2008). The process of lifestyle modification in diabetes patients is always problematic for many patients. Nurses should hold motivation interviews and conversations with patients to encourage diabetes patients to embrace positive behavioral changes (Perry & Collins, 2009).
According to Sobel, (2008), Motivational interviewing is one of the most promising ways of getting behavioral changes in primary care settings. Motivation interviewing is very helpful in adherence to medication, physical activity regimes, quitting smoking, diet regimes and drug abuse reduction.
Nurses should use motivational interviewing besides provision of information and education in primary care to enhance the diabetes patient preparation for change. Motivational interviewing helps nurses resolve the perceptions and factors that may make a diabetes patient ambivalent change (Sobel, 2008).
Goal and Outcomes
The goal of this project is to implement a protocol for motivational interviewing for patients with diabetes at Ben Taub Hospital in Houston Texas. The anticipated outcomes after implementation of this protocol include:
Increased compliance with medication by 30 days after motivational interviewing
Increased physical activity by 30 days after motivational interviewing
Increased patient satisfaction
The goals of the use of motivational interviewing in primary care of diabetes patients should be enhancing the motivation of the patient to embrace change and reducing the resistance of patients to lifestyle modification. The use of motivational interviewing in primary care of diabetes can improve patients’ conformity to medication, physical activity, dieting, reducing drug and alcohol use and smoking. According to Sobel, (2008), motivational interviewing also results in an improvement of the nurse- patient relationships and efficiency of patient consultations in primary care.
Good nurse patient relationships are very essential in management of diabetes care since they can improve the health outcomes in diabetes management. According to Perry & Collins, (2009), Motivational interviewing talks are always associated with successful outcomes in primary care of chronic diseases like diabetes. Motivational interviewing evokes reasons for change from patients themselves by making them have a voice in the process of behavioral change (Sobel, 2008).
Rather than nurses lecturing or instructing patients what to do and the reasons for changing, motivational interviewing talks entail analyzing the responses from patients about the need for change, and encouragement to help patients to embrace change (Sobel, 2008).The focus of motivational interviewing in diabetes management should be supporting the patients in overcoming any barriers to lifestyle modification.
Motivational change talks and interviews are very important in determining the discrepancies between patients’ words of embracing change and the patient actions. Motivational interviewing also helps nurses to assess the patient readiness to change. If the nurses know the stage, at which patients are in their readiness to embrace change, then, it is possible for the nurses to conceptualize patients as being treated at varied stages of acceptance to change process (Sobel, 2008).
Motivational interviewing is very consistent with the role of nurses in modern nursing practice. Modern nursing emphasizes a patient centered approach that factors the views and the needs of the patients in the treatment process (Sampson, 2008). Motivational interviewing is a patient centered approach to treatment that helps in improving the health outcomes of patients (Sobel, 2008).
Good nurse -patient relationships are also highly valued in modern nursing practice. Good patient and nurse relationships are associated with better health outcomes for patients especially in the management of chronic diseases like diabetes (Sampson, 2008).
Motivational interviewing is a tool that motivates and inspires patients to embrace positive behaviors change and, helps nurses in improving their relationship with patients.
Nurses are the main stewards of motivational interviewing. The processes of motivational interviewing like follow up and obtaining feedback make nurses the stewards of the change process in hospital (Sampson, 2008).
Research review
The objectives of motivational interviewing are increasing the motivation of people for behavioral change, and strengthening people’s dedication to embrace change. This technique emphasizes collaboration instead of confrontation, Autonomy instead of authority and evocation over education while handling the behavioral change process in people (Burke et al, 2002).
A very large and rapidly growing body of research has evaluated the effectiveness of motivational interviewing as a behavioral change strategy. Many randomized, Quality, Meta- analytic research studies into the effectiveness of motivational intervention have provided an evidence base that motivational interviewing is an effective behavioral change strategy. Many randomized clinical, controlled studies on motivation interviewing have been published, that support the effectiveness of this strategy (Burke et al, 2002). This paper highlights some of the randomized clinical control studies that prove the effectiveness of motivational interviewing.
1) A meta-analysis by Helen Jones et al, in the year, 2003 examined the treatment of diabetes with the usual techniques compared usual diabetes treatment combined with pathways to change, a motivational interviewing strategy. This meta- analysis evaluated whether pathways to change (PTC) interventions combined with normal diabetes treatment would result to a greater readiness for change in diabetes patients, a greater involvement in diabetes self care and improved diabetes control.
The diabetes patients in this study were classified into two groups, one group received only the normal diabetes treatment (treatment as usual, TAU). The other group received diabetes normal treatment and pathway to change therapy (TAU & PTA). The pathway to change (PTA), motivation technique included tailor-made personalized assessment reports, self help manuals, newsletters and phone interviews for diabetes patients. The pathway to change motivation-interviewing technique was designed to make the patients ready to start diabetes self help programs like glucose monitoring, healthy eating, smoking cessation and physical exercise (Helen et al, 2003).
The total number of participants were 1029 with type one and type two diabetes. Majority of the participants were in the pre-action stages of diabetes self- help programs. The results of this study showed that normal diabetes treatment (TAU) combined with PTC (Pathways to change), resulted in 43.4 percent of the patients moving from pre-action to action stages in blood glucose monitoring compared to 30 percent for those receiving TAU alone (Helen et al, 2003).
For the change of diet interventions, 32 percents of the participants receiving normal diabetes treatment combined with PTC moved from action to maintenance stage. For patients who received normal diabetes treatment, only were 28 percent moved from action to maintenance. For the smoking cessation interventions, 24 percent of the participants receiving diabetes TAU and PTC moved to the action stage compared to 13 percent for patients receiving TAU only (Helen et al, 2003).
The participants who received TAU and PTC decreased their percentage of calories intake by 37 percent, compared to 32 percent for patients who received TAU only. This study demonstrated that motivational interviewing has the potential of positively improving the readiness of diabetes patients to change, and improving health outcomes of individuals with diabetes (Helen et al, 2003).
2)A similar meta-analysis Conducted by Burke et al, (2002), of over 30 randomized clinical trails that utilized motivational interviewing found out that motivational interviewing has average to great impacts in behavioral change. These researchers found out that motivational interviewing has positive effects in the Areas of alcohol use, dieting programs, drug use and social functioning. Motivational interviewing had a motivating effect on behavioral change in patients. Overall, motivational interviewing was found to be an effective behavioral change strategy.
3) Studies into the effectiveness of motivational interviewing have also focused on the effectiveness in reducing substance use, adherence to treatment procedures and medication as well as adherence among people with mental disorders. For example, a randomized control study by Martino et al, (2000), of people suffering from co-occurring disorders found out that, the participants who received just a single session of motivation interviewing in the admission process were more likely to participate in treatment, and adherence to treatment than those who only received the standardized pre- admission interview.
4) Kemp et al, (2006), also employed a form of motivational interviewing in compliance therapy among patients with intermediate psychosis in a hospital inpatient facility. Motivation interviewing therapy increased compliance to medication by the psychotic patients by a factor of 25 percent. This improvement in compliance to medication was maintained six -months after discharge of the patients (Kemp et al, 2006).
A follow up study of the patients in this study also found out that, patients with psychotic disorders had more insight about their diseases and adhered more with treatment and medication. The psychotic patients had a better social functioning and lower hospitalization risk compared to the psychotic patients who did not receive motivational interviewing (Kemp et al, 2006).
5) Motivational interviewing has also found use in the criminal justice system in behavioral change programs for prison inmates. The Crime And Justice Institute, (2004), cited motivational interviewing as an important evidence-based principle for interventions in the criminal justice system. The process of Offender rehabilitation and behavioral change can utilize motivational interviewing to enhance criminal behavior change, the reduction of recidivism and improvement of public safety. Motivational interviewing has been identified as a useful clinical practice for the promotion of behavioral change and treatment responsively in offenders (Criminal and Justice Institute, 2004).
Motivational interviewing is therefore, a very effective approach in behavioral change programs involving lifestyle modifications, adherence to treatment procedures and medication and maintenance of positive adoptive behaviors. The technique has been used in behavioral change programs that involve healthy behavioral changes. The effectiveness of motivational interviewing in eliciting positive behavioral changes makes it ideal for use in diabetes management.
Communication points
Motivational interviewing is a very gentle, emphatic and skillful style of counseling that can help health care practitioners have some fruitful conversation with patients suffering from co-occurring and other lifestyle disease. Motivational interviewing is characterized by empathy through the process of reflective listening, avoiding argumentation and encouraging the client that there is hope of changing (Burke et al, 2007).
Motivational interviewing also involves gently persuasion, listening rather than instructing, and providing support to patients throughout the process of recovery. Motivational interviewing is a collaborative conversation and a decision making process between a health practitioner and the patient receiving treatment (Miller & Arkowitz, 2007).
Although the process of motivational interviewing involves many stakeholders, only the patient can make the initiative in changing behavior and lifestyle to improve their health and change their destructive behaviors (Miller & Arkowitz, 2007).
The key stakeholders that need to be involved in this motivational interviewing change improvement project include,
Diabetes Patient’s immediate families
Primary care staff and providers including nurses and other health care practitioners
Chief of primary care
Hospital management
Patients
Communication points with the key stakeholders
Patients
Motivational interviewing is type of communication that respects the views of the patients in this change process. Nurses and other health practitioners should avoid lecturing to patients about the need for change. The change talk between the patient and the primary care givers should be a two way talk that identifies the needs of the clients (Miller & Rollnick, 2002).
The role of the primary care giver should be asking the patients open ended questions that give patients the latitude to control the conversation. The questions that primary care givers ask the patients should elicit change talk from the patients. According to Miller & Rollnick, (2002), Examples of the questions that primary care givers can ask the patients are,
1) What would you want to change about your current situation?
2) What can I help you with to embrace the change process?
3) What are you having problems with in embracing lifestyle changes?
These kinds of questions would allow the patient to tell their story in their own way.
Primary care givers
Primary care givers should follow the Lippit, Watson and Wesley change theory in applying motivational interviewing. The steps that that are followed in this Lippit Watson & Wesley change theory include need to follow include,
1) Diagnosis of the patient problem
2) Assessing the capacity and motivation to change
3) Assessing the resources of the change agents
4) The selection of change strategies
5) A clear designation of the roles of the change agents
6) Communication of feedback and coordination for the maintenance of change
7) A gradual termination of the helping relationship
The communication points in the interview between the nurse and the patient should entail assisting the knowledge and attitudes of the client regarding physical exercise, improved nutrition, drugs and alcohol use and compliance to diabetes medication. The primary care giver should assess the knowledge, the behavior and the status of patient in readiness to change, advise the patient on health risks and the benefits of change process (Burke et al, 2007).
The primary care giver should collaborate with patients on attaining some feasible goals; assist the patients in anticipating barriers to change and completing the change action plan. The primary care giver should also arrange for a specific plan for follow up and links to clinics and community resources (Miller & Arkowitz, 2007).
Nurses and the health practitioners are the pillars of the change process in motivational interviewing (Burke et al, 2007). The communication points for nurses in this change project would entail communication about the benefits of motivational interviewing in behavioral change process; need to learn motivational interviewing skills and development, and application of the motivational interviewing in diabetes control. The use of nursing skills to enhance motivational interviewing would also be an appropriate communication point for nurses in this change project.
Diabetes patient’s immediate family members
The communication points for the primary care givers to the families of the patients should include enhancing and encouraging the patients in the change process (Miller & Arkowitz, 2007). This can ensure that the patients remain within the set plans and goals of the change process.
Head of primary care
The communication points with the head of primary care should entail the benefits of motivational interviewing in the process of diabetes care, the need for inclusion of motivational interviewing programs in the continuum of diabetes care and the need for nurses to learn the skills of using motivational interviewing
Hospital management
The communication points of primary care giver with the hospital management should include the benefits of motivational interviewing in primary care. The need for resource allocation into the training of primary care givers in motivational interviewing are also good communication points (Miller & Arkowitz, 2007).
Anticipating blockages and strategies of overcoming them
One of the main challenges that face the process of motivational interviewing is the lack of enough time by primary care givers to engage in motivational interviews with patients (Miller & Rollnick, 2002). According to Miller & Arkowitz, (2007), other challenges that motivational interviewing faces are,
2) Initiation of the discussion around lifestyle modification is always a challenge for many patients.
3) Lack of sufficient follow up plans for patients.
4) Lack of knowledge and counseling skills about motivational interviewing by the health practitioners
5) Lack of resources to support fully the process of motivational interviewing.
The barrier of primary care givers having little time with patients for motivational interviews can be reduced through the overhaul of the process of primary care for diabetes patients. The process of primary care for diabetes patients should include the process of motivational interviewing in the continuum of diabetes care.
The Enrollment of nurses in motivational interviewing programs can enhance their counseling skills and make them able to initiate meaningful conversations with patients. Operationalization of motivational interviewing in primary care for diabetes patients
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The institutionalizing of motivational interviewing techniques in patient care is always a challenge for many health care organizations. The process is costly because it requires continuous training of health care providers, great involvement of health care practitioners and periodic evaluation (Butler et al, 2007).
In the process of operationalizing motivational interviewing for diabetes care, it is necessary for the management of health care organizations to provide the necessary resources and support for training of health practitioners and the evaluation of the Operationalization process.
Proposed budget for the Operationalization of motivational interviewing for diabetes patients AT Ben Taub hospital
Activity
Timeline
Cost in dollars
Initial training of primary care providers in motivational interviewing
2 weeks continuous training
500 dollars per a primary care provider per day
Total cost for ten nurses =60,000 dollars
Periodic, continuous training of primary care providers
1 week every year
3000 dollars per nurse total cost 30,000 dollars
Overhaul of the process of provision primary care
2 weeks
20,000 dollars
Evaluation and provision of feedback
continuous
30,000 per year
Total cost= 140,000 dollars
Training of primary care providers
The Provision of primary care for diabetes is a process that relies on communication, feedback and collaboration between primary care providers and patients. According to Miller & Rollnick, (2007), although primary care providers utilize guidelines on handling difficult conversations with patients who have ambivalence to change, many primary care providers do not know how to handle difficult patients.
Many primary care providers also struggle to support the autonomy of patients when they disagree with the choices of the patients. Training of primary care providers in Motivational interviewing can help primary care providers address the concerns of patient ambivalence and support of patient choices. The elements of motivational interviewing are applicable at different settings in healthcare (Miller & Rollnick, 2007).
Training of primary care providers to know which element to use for every patient is necessary in the Operationalization of this program. Primary care providers in hospitals need to learn the eight stages of motivational interviewing by Miller & Moyers (2007) as outlined in the table.
Stage of motivation interviewing
Description
Allocated Time
1)The spirit of motivational interviewing
Openness in thinking, respect for patient autonomy and suspension of authoritarian rule.
0ne day
2)Acquisition of 3)Client centered counseling skills
Proficiency in client centered skills of counseling to provide a facilitative and supportive role to clients.
Two to three days
Recognizing ad sustaining change talk
Learning how to initiate and maintain change talk in clients so that they can explore their ambivalence.
2-3 days
Initiating and strengthening change talk
Learning the ability to evoke and reinforce patient change talks and language commitment
Rolling with sustenance talk and handling resistance from clients
Ability to handle resistance and sustenance of change behavior with respect for patient autonomy
2-3 days
Developing change plans
Learning to negotiate specific change plans in a manner that is acceptable to clients
2-3 days
Consolidation of commitment from clients
Implementation intentions and strengthening of change behavior
2days
Transition and blending of motivational interviewing with other strategies
Learning the ability to blend motivational interviewing with other interventions strategies
1 day
Institutionalization of motivation interviewing in the organization
After training of the primary care providers in the concepts of the motivational interviewing, the next step in the Operationalization of the program should be laying the necessary infrastructure in place to support motivational interviewing.
An overhaul of the process of providing care to diabetes patients is necessary in the Operationalization of motivational interviewing in the areas outlined below.
1)The revision of the process of providing primary care to diabetes patients to include more time for diabetes patients with primary care providers .
2) Allocation and provision of many channels of communication between primary care providers and patients.
3) The provision of many avenues for feedback between patients and the primary care providers.
4) Provision for periodic one-on-one interviews between the diabetes patients and primary care providers so that they can have enough time for motivational interviews.
5) Elimination of bureaucracy in consultations between diabetes patients and primary care providers
6) Provision for Continuous training of primary care providers about new advances in motivational interviewing techniques can also enhance the Operationalization of motivational interviewing in the organization.
Periodic evaluation and review of motivation interviewing
The periodic review of the success of motivational interviewing programs is essential for the Operationalization of motivational interviewing in any organization. Periodic review of the success of the organization in motivational interviewing is suitable for benchmarking. Benchmarking can help health care organizations pinpoint into the areas where primary care providers are not utilizing motivational interviewing techniques properly (Butler et al, 2007). The measures that can be used in the evaluation process include,
1) An increase in the number of diabetes patients accessing motivational interviewing techniques
2) Improvement in the health outcomes of diabetes patients
3) Provision of more feedback from patients regarding their diabetes management programs.
The process of institutionalizing motivational interviewing in primary care is a continuous process (Miller & Rollnick, 2007). In the Operationalization of this project, the stakeholders of these project Health care organizations should therefore make the necessary arrangements to ensure that health care practitioners utilize motivational interviewing techniques technique in a continuous basis in primary care.
Evaluation parameters
The effectiveness of motivational interviewing techniques in eliciting behavioral change is determined by the skill of the health care practitioners in using motivational interviewing techniques and the degree of collaboration by the patient. The success of Motivational interviewing is determined by how best it motivates people in meeting the goals of the change process (Butler et al, 2007).
In this change program on the use of motivational interviewing to motivate diabetic patients to embrace positive lifestyles, the effectiveness of motivational intervention can be evaluated on how it meets the health outcomes of the diabetic patients. The health outcomes that will be evaluated in this project include,
Increased compliance with medication by 30 days after motivational interviewing
Increased physical activity by 30 days after motivational interviewing
Increased patient satisfaction
The overall effectiveness of the motivational interviewing in this change program can be determined by how it improves the diabetic patient health outcomes. According to Steinberg, (2012), some of the parameters that can be evaluated in the determination of the overall effectiveness of motivational interviewing include,
1) A reduction of the complications of diabetes in patients
2) The degree of adherence by patient to diabetes medication regimes.
3) The ability of patients to stick to healthy lifestyles. Examples of the healthy lifestyles parameters that can be used in the determination of the effectiveness of motivational interviewing include,
a) Increase in the level of physical activity
b) Reduction or the quitting alcohol.
c) Improved adherence to the schedules of self monitoring of blood glucose.
d) Willingness to talk and initiate change task with primary care providers.
e) The adherence to the schedule of physician consultations.
According to Steinberg, (2012), the other parameters that can be used to evaluate the effectiveness of motivational interviewing include,
I) Reduction of patient ambivalence
Patient ambivalence is a serious problem for diabetic patients. The effectiveness of motivational interviewing can be evaluated on how it meets the goals of reducing patient ambivalence to the process of change in diabetic patients. The elimination and the reduction of ambivalence to change to healthier lifestyles can help diabetes patients obtain better health outcomes (Steinberg, 2012).
ii) Determination of the discrepancy between a patients promised behavior and actual behaviors
Many diabetes patients have problems maintaining lifestyle changes and acquired behaviors. The discrepancy between a patient’s actual behavior and the promised behavior can provide an overview of how a patient is motivated in the change process. Less motivated patients display a high discrepancy between actual and promised behavior compared to patients who are highly motivated (Steinberg, 2012).
Iii) The level of engagement between primary care providers and patients
Lack of sufficient skills on motivational interviewing by health care practitioners is one of the major problems that limit the effectiveness of motivational interviewing in behavioral change programs. The skill level of primary care providers in motivational interviewing is an indication of the level of engagement between clients and providers (Steinberg, 2012).
Skillful health care providers work fully to understand the client’s perspectives before they can initiate change talk. Skilled healthcare providers also focus on engaging the patient before the initiation of the change talk. They also build positive relationships between them and the patient. The level of engagement between the patient and the health care providers can be used to determine the effectiveness of the motivational interviewing (Steinberg, 2012).
iv) Assessing the level of motivational of patients in embracing change
Motivation is a very important factor for clients in the behavioral change process. Highly motivated patients are not ambivalent to change and have no problems sustaining acquired behaviors (Steinberg, 2012).
The level of motivation of diabetes patients to embrace change can be used a san indicator of how effective primary care providers are in motivating patients to embrace change. The level of motivation of patients motivation can therefore, be used to evaluate the effectiveness of motivational interviewing (Steinberg, 2012).
Importance of the evaluation in motivational interviewing
Measuring the health outcomes of diabetes patients is very essential in the evaluation of the effectiveness of motivational interviewing in diabetes care. These health outcomes represent the necessarily behavioral choices that diabetic patients need to adhere to improve their management of diabetes (Steinberg, 2012).
The Observance of healthy lifestyles is very essential for the diabetic patients to manage their illness. The evaluation of the health outcomes for diabetic patients should be a continuous process because diabetes is a lifestyle disease. The Continued evaluation of the health parameters is very essential in primary care of diabetes. The evaluation of these health parameters allows primary care providers to use different motivational interviewing strategies to enhance the change process in patients (Steinberg, 2012).
The evaluation of these health outcomes of diabetes patients is very essential as it can make the health care provider identify the areas where patients are not meeting the standards of good self care of diabetes .Health care providers can utilize a different strategy to motivate patient to change from the evaluation process. For example, a primary care provider can notice that a diabetes patient is not eating a healthy diet but meets all other criteria of observing a healthy lifestyle. The primary care provider can then utilize another motivational interviewing technique to motivate the patient to observe change to a healthy diet (Steinberg, 2012).
The evaluation of motivational interviewing effectiveness is also essential for the benchmarking process by health care organizations in their endeavor of improving health outcomes of patients (Miller & Rollnick, 2002).
Conclusion
Motivational interviewing is a technique that can be used at Ben Taub hospital to improve the health outcomes of diabetes patients. The implementation of this change program can help diabetes patients overcome their ambivalent to change. The implementation of motivational interviewing requires a continuous commitment from the hospital management and primary care providers to make this project a success.
Motivational interviewing requires the investment of resources and time from the primary care givers and hospital. The effective and continuous implementation of motivational interviewing can help Ben Taub hospital to improve the standards of diabetes care at the hospital.
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