Patient Counseling FINAL (2nd half)

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VASUpharm14
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52019
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Patient Counseling FINAL (2nd half)
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2010-12-05 03:08:02
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im too cool
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well it's that time again, finals. the soul sucker, watch us squirm ... it means we are learning and thinking hard.
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  1. context: medication history (Johnson)
    6 important reasons for interviewing patient
    • 1. establishes professional relationship
    • 2. can obtain subjective information on medical problems
    • 3. can assess drug efficacy and toxicity
    • 4. can assess patient's knowledge, attitude toward, and pattern of medication use
    • 5. helps formulate a problem list
    • 6. helps formulate plans for medication teaching and pharmceutical care
  2. context: medication history (Johnson)
    7 goals of the medication history
    • 1. obtain a current medication list (prescription and OTC medication)
    • 2. obtain a history of past medication usage
    • 3. intended purpose or indication for each of the current medications
    • 4. assessment of therapeutic benefit of current medications
    • 5. assessments of adverse effects from any of the current medications
    • 6. assessment of medication compliance
    • 7. obtain history of drug allergies and adverse drug reactions
  3. context: medication history (Johnson)
    4 steps in opening the interview
    (1) greet the patient warmly --> (2) introduce yourself --> (3) verify identity of patient and caregiver(s) if present [direct questions to the patient unless he/she is unable to give valid information] --> (4) state the purpose of the interview and the expected outcome for the patient [ex: 'Mrs. Smith, I want to speak with you about your medications you are taking, how they are working, and if they are causing you any side effects."]
  4. context: medication history (Johnson)
    4 conditions for setting the stage for the interview
    • 1. Read the chart or patient profile first
    • 2. If previously unplanned, let the patient know how the interview will last to determine if it is a convenient time
    • 3. Make the setting as private as possible
    • 4. Know and complete the 6 ground rules for conducting an interview
  5. context: medication history (Johnson) - 4 conditions for setting the state for the interview
    2 ways to make the setting as private as possible
    • 1. arrange furniture to allow face to face communication at eye level
    • 2. sit 2-4 feet from the patient
  6. context: medication history (Johnson) - 4 conditions for setting the state for the interview
    Name the 6 "Ground Rules" for conducting an interview
    • 1. do not appear rushed
    • 2. be polite
    • 3. be attentive
    • 4. be nonjudgemental
    • 5. listen more than you talk
    • 6. maintain good nonverbal communication
    • - maintain good eye contact
    • - slightly forward lean and open body posture
  7. context: medication history (Johnson) - control the flow of information (6)
    use open-ended, broad questions
    • to start data gathering
    • open-ended questions start with who, what, where, and why
    • ex: Tell about the medications you are currently taking
  8. context: medication history (Johnson) - control the flow of information (6)
    move to close-ended or forced choice questions
    • for discriminating details
    • closed-ended questions can be answered with a yes or no
    • use sparingly - limit patient's response and do not allow for other information to be revealed
  9. context: medication history (Johnson) - control the flow of information (6)
    ask the patient to demonstrate a technique or skill
    if pertinent
  10. context: medication history (Johnson) - control the flow of information (6)
    paraphrase the pertinent points
    • after obtaining a block of related information
    • ex: "Mrs. Smith, you've told me that you are taking HCTZ and digoxin for your heart, and you used to take potassium, but you're not on it right now and you're concerned that you need it. Is that correct?
  11. context: medication history (Johnson) - control the flow of information (6)
    use transitional statements
    • to let the patient know you are asking about a different type of information
    • ex: after taking a current medication history, the pharmacist might say, "Now I'd like to ask about your allergies or reactions to medications you've had."
  12. context: medication history (Johnson) - control the flow of information (6)
    3 opportunities to getting the rambling patient back on track
    • 1. know what needs to be asked and politely defer questions that are not pertinent to the drug history
    • 2. look for openings to bring the subject into focus
    • 3. when it becomes necessary to interrupt, address the patient by name and simply state your need to ask a certain question
  13. context: medication history (Johnson)
    Name 7 pieces of information to obtain
    • 1. current prescribed medications
    • 2. current non-prescription medications
    • 3. past medication usage
    • 4. drug allergies and adverse reactions
    • 5. medication compliance
    • 6. possibility of pregnancy/breastfeeding in women of child-bearing age
    • 7. social history
  14. context: medication history (Johnson) - 7 pieces of information to obtain
    6 facts of current prescribed medications
    • 1. drug name
    • 2. purpose
    • 3. dose
    • 4. duration
    • 5. beneficial effects/efficacy
    • 6. adverse effects/toxicity
  15. context: medication history (Johnson) - 6 facts of current prescribed medications
    8 key symptoms questions for adverse effects/toxicity
    • Start first by saying, "Tell me more about it."
    • 1. onset/timing: when did you notice this? when did it start?
    • 2. duration: how long have you had this problem?
    • 3. content: under what circumstances does this symptom appear?
    • 4. quality: what does it feel like?
    • 5. quantity: how much, how often do you notice it?
    • 6. treatment: what makes it better? what have you done about it?
    • 7. aggravating factors: what makes it worse?
    • 8. associated symptoms: what other symptoms are you having?
  16. context: medication history (Johnson) - 7 pieces of information to obtain
    6 facts of current nonprescription medications
    • 1. drug name
    • 2. purpose/symptoms treated
    • 3. dose and frequency of use
    • 4. duration
    • 5. beneficial effects/efficacy
    • 6. adverse effects/toxicity
  17. context: medication history (Johnson) - 7 pieces of information to obtain
    4 facts of past medication use
    • 1. drug name
    • 2. purpose
    • 3. time period of use
    • 4. reason for discontinuation (why and who)
  18. context: medication history (Johnson) - 7 pieces of information to obtain
    3 facts of drug allergies and adverse reactions
    • 1. drug name
    • 2. date of reaction
    • 3. type and severity of reaction
  19. context: medication history (Johnson) - 7 pieces of information to obtain
    9 facts of social history
    • 1. nicotine usage - quantity; duration; If stopped, when?
    • 2. alcohol usage - quantity; type; duration; If stopped, when?
    • 3. illicit drug usage - quantity; type; duration
    • 4. dietary habits
    • 5. exercise - type of activity; frequency
    • 6. occupation
    • 7. stressors
    • 8. financial situation- insurance vs. out of pocket
    • 9. social support system
  20. context: medication history (Johnson)
    Process of closing the interview
    • (1) give brief summary of the most important points
    • 1. note concerns that you or the patient has about the medications and recommendations for resolution of problems
    • 2. ask patient to verify agreement on the issues
    • --> (2) ask if the patient has anything else to ask or add --> (3) thank the patient for meeting with you- call them by name
  21. context: medication history (Johnson)
    4 information that is documented
    • 1. current prescription and OTC medication list
    • 2. past medications
    • 3. drug allergies and reaction type
    • 4. social history
  22. context: medication history (Johnson)
    T/F maintain patient confidentiality
    True.
  23. context: communicating with difficult and angry patients (Stolte)
    4 characteristics of anger
    • builds: escalating emotion
    • 1. part of being human
    • 2. sometimes for good reason, sometimes not
    • 3. very difficult emotion
    • 4. may result in unclear thinking and impaired ability to solve problems
  24. context: communicating with difficult and angry patients (Stolte)
    4 thoughts about managing anger
    • 1. no quick fixes or easy advice
    • 2. how do you respond to anger?
    • 3. do your responses escalate others?
    • 4. do your responses focus on solving problems? should be.
  25. context: communicating with difficult and angry patients (Stolte)
    8 points about anger (what is anger?)
    • 1. just a feeling
    • 2. not inherently good or bad
    • 3. no worse or better than joy, hurt, or fear
    • 4. feeling angry is not what causes the problems
    • 5. it is what we choose to do when we feel angry
    • 6. almost always a secondary emotion
    • 7. fear and hurt are often the primary emotion trigger
    • 8. often used to block off physical or emotional pain
    • ex: getting angry when publicly criticized because it feels better and more powerful than the primary emotion (primary emotion = embarrassment, fear of being different) - address the primary emotion and talk to the person in one-on-one time instead of for show.
  26. context: communicating with difficult and angry patients (Stolte)
    2 points in time when anger creates problems
    • 1. we use it to escape the core feelings we use it to mask - not addressing the fear/underlying problem - solve by privately discussing it. (problem-solving)
    • 2. we suppress or repress anger or express it inappropriately
  27. context: communicating with difficult and angry patients (Stolte) - when anger creates problems
    suppressed or repressed anger
    • -builds up and is eventually released in some form of an explosion
    • -a lot of little anger > a little of a lot of anger (blow-up)
    • -linked with development of medical conditions (PUD, CVD) - when not expressing anger (holding it in)
    • -causes us to lose information about who we are - need to be able to recognize when we are hurt or afraid so we can grow and mature (so angry and losing sight of the origin of problem)
  28. context: communicating with difficult and angry patients (Stolte) - when anger creates problem
    3 forms of inappropriate expression of anger
    • 1. rage
    • 2. passive-aggressive behavior
    • 3. defensiveness
    • results: cause damage to others and real issues do not get addressed
  29. context: communicating with difficult and angry patients (Stolte)
    • primary --> trigger --> secondary
  30. context: communicating with difficult and angry patients (Stolte)
    2 types of stressors
    • 1. physical stress
    • 2. emotional stress
    • ex: a patient who complains (stressor) a lot, and pharmacist says he/she cannot deal with it (self-fulfilling prophecy). (core feeling = ignorance, powerless, fear, dread) due to: bias?, or last experience.
    • problem solving: only address problems that have some control over (this case: no control)
  31. context: communicating with difficult and angry patients (Stolte)
    examples of trigger statements
    • comments we make to ourselves (sometimes out loud) in response to the stressor or painful core feelings which then turns core feeling into anger because beliefs, expectations, values are not how we believe they should be (the plane is in a holding pattern due to weather).
    • -"why does he always have to complain?"
    • -"why does he always come in when I am working?"
  32. context: communicating with difficult and angry patients (Stolte)
    3 rules for appropriate expression of anger
    • 1. once you decide to practice pharmacy, you make the decision to serve people
    • 2. to operate effectively as professionals, the patient is not always right
    • 3. "The patient is always right" should be replaced with "The patient deserves respect"
  33. context: communicating with difficult and angry patients (Stolte) - 3 rules for appropriate expression of anger
    once you decide to practice pharmacy, you make the decision to serve people
    • you enter into a nonreciprocal relationship with your patients (don't expect anything in return- give and never expect to receive)
    • you do not lose your self respect (come up with your own line)
  34. context: communicating with difficult and angry patients (Stolte) - 3 rules for appropriate expression of anger
    to operate effectively as professionals, the patient is not always right
    • if patient says there was a shortage of tablets, yet profile said counted was done three times, who is right? not the patient, you are the professional
    • upper management cannot have it both ways
  35. context: communicating with difficult and angry patients (Stolte) - 3 rules for appropriate expression of anger
    "the patient deserves respect"
    • respect for people cannot be diminished by bad behavior and is not dependent on accomplishments
    • do not have to like behavior and do not have to put up with it - clean slate next visit when patient acknowledges and willing to change. (respectfully tell them that they are wrong, don't say right if they aren't)
    • you do not deserve to be disrespected either - you need guts (don't ignore- inappropriate).
  36. context: communicating with difficult and angry patients (Stolte) - 3 rules for appropriate expression of anger
    6 things we should do
    • 1. listen
    • 2. be empathetic
    • 3. respect the other
    • 4. respect yourself
    • 5. remain separate from others - just a job/not life
    • 6. communicate assertively
  37. context: health literacy (Stolte)
    what is health literacy?
    • how well a patient knows the medical procedures and terminology
    • literacy: ability to read and write
    • health literacy: ability to read and understand health literature or health information provided to a patient. The patient's ability to read and understand the information that is provided to them that is related to health, wellness, and medicine.
  38. context: health literacy (Stolte)
    % of adult Americans (40-44 million) are functionally illiterate and read at or below the 5th grade level
    21%
  39. context: health literacy (Stolte)
    average age patients read at
    • 8th or 9th grade level
    • bias sample because those who can afford any healthcare or even care about health will come
  40. context: health literacy (Stolte)
    most health materials are written at what grade level?
    > 10th grade
  41. context: health literacy (Stolte)
    % additional of adults (50 million) are only marginally illiterate
    1/4; 25%; a quarter
  42. context: health literacy (Stolte)
    % of U.S. adults age 60 and over have either inadequate or marginal literacy skills
    more than 66% or more than 2/3rds
  43. context: health literacy (Stolte)
    T/F there is a stigma with illiteracy
    True
  44. context: health literacy (Stolte)
    % had never told their spouse
    2/3rds
  45. context: health literacy (Stolte)
    % has never told anyone of his or her reading problem
    19%
  46. context: health literacy (Stolte)
    T/F they are not as adept at hiding their inability to understand and make sense of written and oral communication
    false. most are adept
  47. context: health literacy (Stolte)
    4 reasons health literacy matter
    • patients with marginal literacy:
    • 1. make more significant medication or treatment errors
    • 2. far less likely to adhere to their medication regimens
    • 3. fail to seek preventative care more
    • 4. less preventative overall in their health, don't engage in any form of preventative care like nutrition, diet, and exercise
  48. context: health literacy (Stolte)
    5/6 ways to recognize someone with low literacy
    • 1. when you ask them to fill out forms or complete medication history and they ask many questions, want to bring it home, complain about font, or have someone else do it, etc)
    • 2. making excuses for not reading labels when asked to do so
    • 3. patients doesn't know names of the medications they've been taking for a long time
    • 4. registration or other types of forms are filled incompletely or incorrectly
    • 5. overall expressed disinterest and show that they don't care about it
  49. context: health literacy (Stolte)
    6 problematic tasks for patients with low health literacy
    • 1. reading consent forms
    • 2. registering for care or filling out patient history forms (difficult for them)
    • 3. filling out financial aid forms is difficult/payment issues
    • 4. reading medicine labels
    • 5. understanding other types of written health information like brochures, monographs
    • 6. even understanding a complex medication regimen
  50. context: health literacy (Stolte)
    4 coping mechanisms used by low-literate patients
    • 1. bring someone who can read
    • 2. mimicking behaviors
    • 3. asking help from medical staff
    • 4. asking other patients
  51. context: health literacy (Stolte)
    4 of many strategies to improve patient education materials
    • 1. pictures, symbols, diagrams (since brochures and monographs are usually in all words)
    • 2. any material should be written at 5th grade level
    • 3. use common words
    • 4. ask them to watch videos (check credibility first)
  52. context: health literacy (Stolte)
    4 of many provider (us) strategies to help low-literate patients (what can we do?)
    • 1. encouragement (ex- to bring someone)
    • 2. for directions- use pill boxes, identifier for blind, color coded, associating with daily events vs time to make it more relatable
    • 3. follow-up with patient
    • 4. speak more slowly
  53. context: conflict management and assertiveness (Stolte)
    quotes about conflict
    • 1. the absence of conflict is not harmony, it's apathy
    • 2. conflict is essential to innovation
    • 3. conflict is natural, even necessary
    • 4. reasonable people, making decisions under conditions of uncertainty, are likely to have honest disagreements over the best path
    • *conflict is not always bad; a disagreement
    • *not important enough or have fear
  54. context: conflict management and assertiveness (Stolte)
    why does healthy conflict turn unproductive?
    • 1. focus on people rather than problem at hand
    • 2. people saying you're not good enough, personalize it and we feel afraid
  55. context: conflict management and assertiveness (Stolte)
    when confronted with a problem, 3 things you could do
    • 1. moan about it
    • 2. avoid it - absence of decision can be a problem
    • 3. solve it - can be a problem if you oversimplify and not listen to others
    • *key: be honest with yourself
  56. context: conflict management and assertiveness (Stolte)
    "Neurosis is a substitute for legitimate suffering" - Carl Jung
    This means?
    • the cultural problems especially in America is that we don't show grief well or afraid to show grief
    • neurosis: disorder we use to substitute legitimate suffering which is the better way.
  57. context: conflict management and assertiveness (Stolte)
    6 causes of conflict
    • 1. lack of awareness
    • 2. incompatible goals
    • 3. scarce resources - doing more with less like having less staff
    • 4. dependence
    • 5. values (morals)
    • 6. resistance to change
  58. context: conflict management and assertiveness (Stolte)
    what is the first rule of conflict that MUST be accepted?
    for a healthy conflict, you are not always right
  59. context: conflict management and assertiveness (Stolte)
    7 good practices for feedback in an environment of disagreement
    • 1. be descriptive rather than judgmental (try to not make it personal)
    • 2. be specific rather than general
    • 3. deal with things that can be changed (past grievances should be kept in the past)
    • 4. give feedback when it is desired - when someone is willing to listen
    • 5. consider the motives for giving and receiving feedback (to help them or to make you feel better?)
    • 6. try to give feedback at the time the behavior takes place, if possible
    • 7. if necessary, give feedback when its accuracy can be checked with others (get others involved for evidence).
  60. context: conflict management and assertiveness (Stolte)
    4 ways/strategy to overcome resistance to change
    • 1. education
    • 2. communication
    • 3. participation
    • 4. problem solving (best one- this is the only win-win strategy for managing conflict)
  61. context: conflict management and assertiveness (Stolte)
    2 key points in problem solving
    • 1. when engaged in a conflict over a problem, focus on the problem, not the person
    • 2. provide feedback rather than accusations
  62. context: conflict management and assertiveness (Stolte)
    5 steps in problem solving
    • 1. identify the problem - define it exactly and specifically and determine who is responsible for the problem
    • 2. identify all possible solutions - requires brainstorming with others because the more possibilities = better chances of finding best solution
    • 3. decide which solution is the best - no perfect compromise
    • 4. determine how to implement the solution
    • 5. assess the outcome of your solution
  63. context: conflict management and assertiveness (Stolte)
    assertiveness
    like confidence, is always a good thing vs. arrogance and cockiness
  64. context: conflict management and assertiveness (Stolte)
    2 actions of assertive people
    • 1. engage in problem solving
    • 2. face conflicts and seek solutions of mutual accord
  65. context: persuasion in communication (Stolte)
    4 reasons why traditional model for implementing behavior is no longer effective
    • traditional - command-and-control
    • due to changing times:
    • 1. busy
    • 2. globally-available information (information from internet)
    • 3. global communication
    • 4. little generational tolerance for unquestioned authority
  66. context: conflict management and assertiveness (Stolte)
    To persuade is to satisfactorily answer what question?
    not just, "what should I do?", but "Why should I do it?"
  67. context: conflict management and assertiveness (Stolte)
    2 misconceptions of persuasion
    • 1. form of manipulation (devious <-- don't do it)
    • 2. selling products and closing deals
  68. context: conflict management and assertiveness (Stolte)
    What is effective persuasion?
    • always involving compromise, leading others to a problem's shared solution
    • a negotiating and learning process
  69. context: conflict management and assertiveness (Stolte)
    4 steps toward effective persuation
    • 1. preparation
    • 2. proper framing of arguments
    • 3. presentation of supporting evidence
    • 4. proper emotional match with your audience
  70. context: conflict management and assertiveness (Stolte)
    3 factors that must be changed or altered for persuasive communication
    • 1. beliefs which lead to
    • 2. attitudes which lead to
    • 3. behaviors - the focus, but must effectively affect all (if there are conflicts) for persuasion
  71. context: conflict management and assertiveness (Stolte)
    example: small business owner Mary H. who believes in and has taken antibiotics. Prescribed new drug that needs to be taken frequently. Will she take it?
    • unknown answer. she might be too busy. don't know her behavior.
    • *This shows that persuasion:
    • -involves compromise
    • -it's likely no one will compromise due to Mary's busy lifestyle and the pharmacist who doesn't intervene = dec. adherence of patient
    • -compromises that could be made include finding other alternative medication
  72. context: conflict management and assertiveness (Stolte)
    T/F effective persuaders enter the process prepared to keep their own viewpoints and not incorporate others' ideas
    False. keep --> adjust; not --> will
  73. context: conflict management and assertiveness (Stolte)
    4 essential/must-haves steps to effective persuasion
    • 1. establish credibility
    • 2. frame goals in a way that identifies common ground with those you intend to persuade
    • 3. reinforce position using vivid language and compelling evidence (best way)
    • 4. connect emotionally
  74. context: conflict management and assertiveness (Stolte) - 4 essential steps to effective persuasion
    establish credibility (most important)
    • has nothing to do with your degree
    • research shows that most professionals considerably overestimate their credibility vs. from patients
    • grows from 2 sources:
    • 1. expertise - proven by track record over degree
    • 2. relationships - honest, steady, reliable
    • *can be built!
    • *step back and honestly assess this
  75. context: conflict management and assertiveness (Stolte) - 4 essential steps to effective persuasion
    frame for common ground (frame goals)
    • position must appeal strongly to the people you are trying to persuade like convincing Dr. Stolte to chase lightning
    • effective persuaders must be adept at describing their positions in terms that illuminate their advantages
    • critical: identify your objective's tangible benefits to the people you are trying to persuade
    • when no mutual benefits exist, persuaders must adjust their position.
  76. context: conflict management and assertiveness (Stolte) - 4 essential steps to effective persuasion
    provide evidence
    • credibility and common ground must first be identified
    • studies have shown that numerical evidence is not sufficient, regardless of discipline
    • numerical data should be supplemented with examples, stories, metaphors, and analogies (listeners absorb information in proportion to its vividness and to make an emotional impact through power of language)
  77. context: conflict management and assertiveness (Stolte) - 4 essential steps to effective persuasion
    connect emotionally
    • good persuaders are aware of the primacy of emotions
    • 2 important characteristics of good persuaders:
    • 1. show their own emotional commitment to the position they are advocating (don't overdo it because they'll doubt your clearheadedness, but show that you are also emotional in heart and gut)
    • 2. have a strong and accurate sense of the audience's emotional state (intuition, networking like through DSM programs), scare them with stats and information and they'll want to know you'll be there to help them like with their children getting better and they aren't being troubled.
  78. context: conflict management and assertiveness (Stolte)
    summary of persuasion
    • complex
    • can be dangerous when mishandled
    • can be a force for enormous good:
    • 1. pull people together
    • 2. move ideas forward
    • 3. galvanize change
    • 4. forge constructive solutions
    • must be viewed as learning and negotiating rather than convincing and selling
    • must be seen as an art from requiring commitment and practice
  79. context: Change and Motivational Interviewing (Stolte)
    "When people are given the choice between changing and proving that it is not necessary most people get busy with the proof." - John Kenneth Galbraith
    challenge is not necessary, just to the work.
  80. context: Change and Motivational Interviewing (Stolte)
    Is change important to us?
    yes
  81. context: Change and Motivational Interviewing (Stolte)
    Managing an illness requires what change (beliefs/attitudes/behaviors)
    behavior
  82. context: Change and Motivational Interviewing (Stolte)
    Does health care, in general, change?
    • Possibly.
    • ex: insurance for everyone, jump in prescriptions
  83. context: Change and Motivational Interviewing (Stolte)
    do pharmacy benefits change?
    copays don't really change. problems with angry patients.
  84. context: Change and Motivational Interviewing (Stolte)
    9 types of emotional reactions to change. which is worse
    • 1. fear, anxiety, and ambivalence
    • 2. anger, blaming, and scapegoating
    • 3. going numb or avoiding
    • 4. excitement, joy and relief
    • 5. frustration
    • 6. depression
    • 7. feeling out of control
    • 8. shame or guilt
    • 9. feeling alone
    • *ambivalence is worst = not thinking about the changes or ramifications.
  85. context: Change and Motivational Interviewing (Stolte)
    7 reasons change is difficult
    • 1. lack of confidence in ability to make transition (pharmacists don't counsel even if required by law back then because they don't see it as their role)
    • 2. lack of understanding of what is needed
    • 3. lack of involvment
    • 4. inability to see personal of professional benefits
    • 5. thinking things are fine as they are
    • 6. wondering whether something you have done wrong has led to the change
    • 7. "I'm too old for this." It won't matter anyway.
  86. context: Change and Motivational Interviewing (Stolte)
    Discovery of the Transtheoretical model of change
    Most addiction therapy is actually based on.
  87. context: Change and Motivational Interviewing (Stolte)
    5 stages of Transtheoretical model of change
    • 1. pre-contemplation
    • 2. contemplation
    • 3. preparation
    • 4. action
    • 5. maintanance
  88. context: Change and Motivational Interviewing (Stolte) - 5 stages of Transtheoretical model of change
    precontemplation
    • 1. characteristics:
    • unaware, unwilling, cons outweighs pros, not ready to try anything within the next 6 months
    • (not thinking about anything at all).
    • ex- want to quit smoking? no
    • 2. interventions by pharmacist:
    • listening, empathetic responses, effective questioning, identifying barriers, nonjudgmental approach, persuasive strategies generally not effective at this point
  89. context: Change and Motivational Interviewing (Stolte) - 5 stages of Transtheoretical model of change
    contemplation
    • 1. characteristics:
    • open (from being closed) to information and education, thinking about trying something within the next 6 months; low self-efficacy; high perceived temptation to stay the same
    • 2. interventions by pharmacist:
    • listening and empathetic responding, educational interventions (area to provide education), emotional support, social support, discuss strategies to remove barriers (assess subconsciously at least of where they are at).
  90. context: Change and Motivational Interviewing (Stolte) - 5 stages of Transtheoretical model of change
    preparation
    • 1. characteristics:
    • ready to engage in behaviors in the next month (ready to do it), have made one prior attempt in the past year, beginning to set goals
    • 2. interventions by pharmacist:
    • listening and empathy, praise for readiness (for even thinking about changing; Fluid Model- progress or relax), assistance in goal setting, discussion of plan of action, identification of pitfalls, asking about support from those around person
  91. context: Change and Motivational Interviewing (Stolte) - 5 stages of Transtheoretical model of change
    action
    • 1. characteristics: taking steps, engaging willpower, developing sense of autonomy, improved self-efficacy; experiencing guilt, failure, personal freedom limits; very stressful stage
    • 2. interventions by pharmacist: listening and empathy, reinforcement of self-efficacious behavior, encouragement, emotional support, especially in the face of relapse, ID reason for relapse, confrontation may be necessary
  92. context: Change and Motivational Interviewing (Stolte) - 5 stages of Transtheoretical model of change
    maintanence
    • 1. characteristics: engaged in new behaviors for at least 6 months, sense of accomplishment established, able to ID behaviors that lead to relapse (unlike New Year's resolutions)
    • 2. interventions: listening and empathy, help assess situations likely to produce relapse, continued support and positive reinforcement
  93. context: Change and Motivational Interviewing (Stolte)
    Motivational Interviewing
    • What is it?
    • -helps you identify patient's readiness to change and understanding
    • -used to negotiate (compromise) behavior change with patient
    • -counters ambivalence
    • --------
    • similar to counseling but instead of just talking about medications, one would help patients change behaviors (big behaviors = quitting smoking, exercising)
    • taking the Transtheoretical Model of Change that the people go through and guiding them through the process. How can we or any healthcare professional get the people to make the change that is beneficial to them and what we want out of it. This will be outside of patient counseling because it will include all the stuff we have talked about like about conflict.
  94. context: Change and Motivational Interviewing (Stolte)
    how many strategies for Motivational interviewing
    6 strategies - not all required for every patient
  95. context: Change and Motivational Interviewing (Stolte)
    how long should it take to use the entire menu of strategies in motivational interviewing
    • 5-15 minutes if you skilled and used only on patients who expressed strong desire to change and employed each time a patient is seen
    • if you are not skilled it could take you hours
  96. context: Change and Motivational Interviewing (Stolte)
    Lifestyle strategy
    • chit chat with a purpose.
    • talk about patient's lifestyle from patient's perspective (getting the context of the behavior)
    • Find if whether or not they know what they are doing/is it healthy or unhealthy? ex- what do you eat? what should you think you should be eating?
    • in reality, people don't know what to do.
    • like/dislike? diet is hard to talk about since everyone likes bad food.
    • aspects needed to change
    • provides general picture and desire to change and identifies what education to provide to the patient to address the misinformation they may have.
  97. context: Change and Motivational Interviewing (Stolte)
    A typical day
    • ask the patient to describe in specifics a typical day related to the behavior in question.
    • what should we identify and how often and more importantly, when.
    • allows pharmacist to design/tailor intervention to the patient.
    • helps improve adherence
    • helps build rapport with patient
  98. context: Change and Motivational Interviewing (Stolte)
    the good and the less good things
    • pharmacist ask questions of the patient to determine which beliefs are accurate and which need to be corrected (developing discrepancy is a key aspect to motivation interviewing)
    • once one decided what is accurate and what is not, ONLY beginning at this point, you will provide information which is different than prior practice. need to target that information. It is more interesting and applicable if you know what the patient wants or needs to know. Education in the form of just providing information does not solve problems by itself which is partly cause of lack of adherence.
    • -helps pharmacist build rapport
    • -allows corrections of misconceptions and current practices
    • -aides in identifying barriers and facilitators of desired behaviors
  99. context: Change and Motivational Interviewing (Stolte)
    providing information
    • NOW we will help with decision making WITH the patient. This is after all the questions.
    • Pharmacist provides information related to how to perform a desired behavior and what to do if they do not perform a desired behavior
    • only provide additional information if patient wants it.
    • provide information in an unbiased nonjudgemental manner.
    • ask them what they want to change today. figure out the "why"
  100. context: Change and Motivational Interviewing (Stolte)
    the future and the present
    • patients discuss their goals as a result of a behavior
    • patients concerns and dissatisfaction will become known at this stage
    • the goal of patient counseling- take the right medicine, at the right time, at the right dosage. empathy is most important.
    • Excuses/barriers- listen to them for this so you can find what appeals to them and what they want as a result.
  101. context: Change and Motivational Interviewing (Stolte)
    helping with decision making
    • first step of intervention
    • ask the patient what he/she plans to do now
    • pharmacist can then help patients make decision about managing illnesses.
    • pharmacist should attempt to remain neutral and nonjudgemental
    • patients will likely be weighing whether to change or stay the same.
  102. context: Change and Motivational Interviewing (Stolte)
    5 principles of motivational interviewing
    • 1. express empathy (very important and is more than in patient counseling)
    • 2. develop discrepancy
    • 3. avoid argumentation
    • 4. roll with resistance
    • 5. support self-efficacy
  103. context: Change and Motivational Interviewing (Stolte) - 5 principles of motivational interviewing
    express empathy
    • do you view the patient as lazy and uncooperative or struggling with the process of change
    • lack of cooperation and interest with or without active resistance is a method of coping with a change
    • try to understand reason for this time from the patient's perspective - open-ended questions, reflective listening, empathetic responding
  104. context: Change and Motivational Interviewing (Stolte) - 5 principles of motivational interviewing
    develop discrepancy
    • compare patient's current behavior with the desired behavior/personal goals
    • better than straightforward persuasion in precontemplation and contemplation
    • create discrepancies without making patient feel threatened
    • let the patients come to the reasons a change is necessary
    • ---
    • the patient has to acknowledge and realize what to do. You can give SOME information to help but the patient needs to know before the plan is put in effect.
  105. context: Change and Motivational Interviewing (Stolte) - 5 principles of motivational interviewing
    avoid argumentation
    • good form of conflict
    • motivational interviewing is confrontational
    • -actual behavior vs desired behavior
    • argumentation usually arises when patients:
    • 1. persuaded they have a problem
    • 2. are labelled
    • arguing fortifies resistance to change
    • ----
    • ultimate barrier- builds the wall
    • avoiding rational behavior - not admitting fault or wrongness during argument.
    • conflict- getting them to change (good if done right)
    • persuade that they have a problem, don't just tell them they do
  106. context: Change and Motivational Interviewing (Stolte) - 5 principles of motivational interviewing
    roll with resistance
    • work around with daily circumstances = their excuses
    • in the end, the change is the patient's job.
    • -when patients express problems or resistance, express understanding of the problem
    • -frustration and anger at the patient will lead to fortified resistance
    • -remember, in the end, the change will be the patient's job, and it is not your responsibility
    • so why get mad (get glad) ... you can't change their minds for some things are out of our control
  107. context: Change and Motivational Interviewing (Stolte) - 5 principles of motivational interviewing
    support self-efficacy
    patients have to believe that they have the knowledge, skills, and abilities to carry out a treatment plan
  108. context: Change and Motivational Interviewing (Stolte) - 5 principles of motivational interviewing
    6 ways we can help build self-efficacy
    • 1. providing and clarifying information
    • 2. offer realistic hope
    • 3. express confidence in patient's ability to succeed
    • 4. notice and point out successful attempts
    • 5. praise patient ideas (pat on the back regardless if they have failed because they tried at least)
    • 6. emphasize and support two-party responsibility and eventually to their own control
  109. FINAL OMG FINAL OMG FINAL OMG
    • Short answer: majority of applications.
    • How apply principles of motivational
    • interviewing to patient who wanted to change x. write out scenario of how you
    • get the person to change.
    • Application and practice. Won’t tell
    • behavior x yet.
    • You can write anything.
    • Q: script out a counseling scenario for drug
    • x. describe how to counsel with 3 key questions, etc. No need to know info on
    • drugs
    • Focus on process and practice.
    • NO FILL IN THE BLANK. Be legible.

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