Transcript Communication skills and motivational

COMMUNICATION SKILLS
AND MOTIVATIONAL
INTERVIEWING
Dr. Omar Alkaradsheh
Outline
Introduction
Communication goals
ADEA competency
Communication pathways
1.
2.
3.
4.
1.
2.
3.
Verbal
Non-verbal
Paraverbal
Listening & listening skills
How to develop good communication skills
Effective communications
Patient Education
Motivational interviewing:
5.
6.
7.
8.
9.
1.
2.
3.
4.
Introduction
Spirit
Principles
Strategies
Introduction
• Communication skills is the ability to use language and
express information.
• Communication requires a sender, a message, a medium
and a recipient.
Don’t we just know how to communicate?
Public and practicing dentists considered communication as
1 of the top 3 most important factors in delivery of dental care.
Nearly 50 percent of dentists felt
that they had received only
fair or poor training in communication.
Dimatteo, McBride, Shugars & O'Neil,1995
Why communicate?
68% to 70%
of medical litigation
cited communication issues
as the primary cause.
Islam and Zyphur, 2007
Competency 3. Communication and Interpersonal Skills.
Graduates must be competent to:
3.1 Apply appropriate interpersonal and
communication skills.
3.2 Apply psychosocial and behavioral principles in
patient-centered health care.
3.3 Communicate effectively with individuals from
diverse populations.
Communication Goals
To change
behavior
To get action
To ensure
understanding
To persuade
To get and give
information
Communication Pathways
Verbal communication- the words we choose
Paraverbal Messages - how we say the words
Nonverbal Messages - our body language
Verbal Communication
Effective Verbal Messages
Are brief, succinct, and organized
Are free of jargon
Do not create resistance, frighten, intimidate or
upset the listener.
Functions of Verbal communications
• Task ordering
• “What are we trying to accomplish?”
• Procedural
• Process orientation
• How we say something.
• Relational/influential
• Narrative
• Helps to describe the situation.
• Use of analogies, metaphors.
Structures of Meaning in Verbal Communication
• Denotative Meaning
• Literal / dictionary meaning.
• Connotative Meaning
• Meaning depends on subjective reality and context.
Harris, 2008
Nonverbal Messages
Nonverbal messages are the primary way that we
communicate emotions
Facial Expression
Postures and Gestures
Nonverbal Communication
Between 65% and 93% of a message’s meaning is nonverbal.
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Facial Display
Body language
Paralanguage
Proxemics
Chronemics
Facial Display
• Facial expressions-Dentist
• Facial expressions- Patient
Eye Contact
Eye contact
• Helps regulate the flow of communications and reflects
interest in others.
• Direct eye contact conveys warmth, credibility and
concern.
• Shifty eye contact suggests dishonesty.
• Downward gaze maybe a sign of submissiveness or
inferiority
Facial Expressions
Paraverbal Messages
Is the meaning received along the actual words through
the vocal delivery of the message
Paraverbal communication refers to the messages that
we transmit through the voice tone, pitch, voices. Dialects,
accent, pitch, tone, rate, pauses…etc.
Body Language
• Physical Appearance
• Movement
• Gestures
Proxemics
• Patients have their own Personal space
• invisible boundary that they create around themselves
• Differ from patient to patient
• Dentist needs to invade this space to provide treatment
• Verbal and nonverbal communications should mitigate the
tension created by this encroachment of their personal
space.
Chronemics
• The use of time
• Wait time for patients communicate their value
• Waiting room
• scheduling
Nonverbal Communications
Understanding Message Reception
A person’s message is perceived in 3 ways:
55% Visually (facial expressions)
33% Vocally (pitch, tone,volume)
7% Verbally
(words)
RECEIVING MESSAGES
Listening
Requires concentration and energy
Involves a psychological connection with the speaker
 Includes a desire and willingness to try and see things
from another's perspective
Requires that we suspend judgment and evaluation
Listening Skills
• Do not let the mind wander.
• Put aside personal concerns while the patient is talking.
• Do not concentrate on formulating a reply.
• Concentrate on what the patient is actually saying.
• Look as well as listen.
• Pick up both the verbal and nonverbal information the patient is
transmitting.
How We Learn
80% occurs through sight alone
10% through hearing
5% through touch
5% through smell and taste.
Sredl & Rothwell, 1987
What makes a good communicator?
Clarity
Adequacy
Integrity
Timing
Effective Communication . . .
It is two way.
It involves active listening.
It reflects the accountability of speaker and
listener.
It utilizes feedback.
It is free of stress.
It is clear.
Barriers to Effective Communication
•Socio-economic level
•Education
•Cultural Diversity
JAMA, 2009: Kundhal & Kundhal, 2009
Cultural Diversity
• Differences in race, gender, cultural heritage, age,
physical abilities, and spiritual beliefs are variations that
must be appreciated and understood when working with
patients and other staff members.
How do you develop your communication skills?
Explore the related skills
Tips to good communication skills
Maintain eye contact with the audience
Body awareness
Gestures and expressions
Convey one's thoughts
Practice effective communication skills
Patient Education & Motivational
Interviewing
Patient Education
• Clinician-Centred
• Educational messages and direct advice provided using a
unidirectional form of communication that attempts to
persuade patients to comply with professional
recommendations.
• This puts the patient in the position of either passively
accepting or, alternatively resisting the often unsolicited
advice.
Traditional Patient Education
Classic approaches to Oral Health Education and Behaviour Change
Knowledge
If I tell them that their oral condition might
affect their heart health, they will change.
Insight
If I show them that they have gingival
inflammation, they will change.
Skill
If I teach them how, they will change.
Threats
If I make them feel bad or afraid, they will
change.
Motivational Interviewing (MI)
“a collaborative, person-centred, goal-directed method
of communication for eliciting and strengthening
intrinsic motivation for positive change.”
Miller, Moyers, Rollnick; 2009
Motivational Interviewing (MI)
• MI is a well-accepted strategy for behaviour change
consistent with contemporary theories of behaviour
change.
• MI positively affect health behaviour change related to
drug addiction, smoking, weight reduction, diabetes
management, medication adherence, condom use, and
oral health.
Motivational Interviewing (MI)
• Through experience, Miller found the likelihood for positive change
occurred more readily when the clinician connected the change with
what was valued by the patient.
• He also found confrontational styles or direct persuasion are likely to
increase resistance and should be avoided.
• A theory that motivation is necessary for change to occur - resides
within the individual and is achievable by eliciting personal
values/desires and ability to change.
•
It is based on allowing the patient to interpret and integrate health
and behaviour change information if perceived as relevant to his/her
own situation.
• It acknowledges the patient is the expert in their own life.
MI Pyramid
The “Spirit” of Motivational Interviewing
• The foundation for MI rests not in the specific strategies or use of a
set of technical interventions but on a sincere “spirit” of mutual
respect and collaboration.
• Literature has emphasized that in order to be an effective MI
practitioner it is more important to embody the underlying philosophy
or spirit than to be able to apply the collection of techniques.
• The clinician must abandon the impulse to solve the patient’s
problems (often referred to as the “righting reflex”) and allow the
patient to articulate his or her own solutions.
The Spirit of MI is based on three key elements:
I.
Collaboration (Vs. Confrontation) between the
therapist and the client;
II.
Evoking or drawing out the client‘s ideas about
change; (Rather than imposing ideas)
III. Autonomy of the client.(vs. Authority)
• Even such basic matters as how the patient and practitioner
are seated can contribute to the patient feeling like they are
truly being invited to engage in a dialogue as a partner, rather
than feeling they are simply to be the recipient of expert advice.
Inappropriate position for a conversation:
the clinician is wearing a face mask and is
at a higher level than the supine patient.
Appropriate position for a conversation:
clinician is facing the patient on the
same seating level.
Principles of MI
Four General Principles
1. Express Empathy through acceptance, affirmation, openended questions and reflective listening.
2. Develop Discrepancies between current behaviour and
important goals or values.
3. Roll with Resistance and avoid arguing.
4. Support Self-efficacy and optimism. Enhance the patient’s
confidence in their ability to make a change.
Motivational Interviewing Skills and Strategies
OARS
• OARS: Open Ended Questions, Affirmations, Reflections,
and Summaries
• Brief method to begin MI.
• These are Core counsellor behaviours employed to move
the process toward eliciting client “change talk” and
commitment for change.
• Change talk involves statements or non‐verbal
communications indicating the client may be considering
the possibility of change.
OARS
• Ask open-ended questions: Approaching the patient with
multiple closed-ended questions (question that will be
answered with “yes” or “no”) sets the patient’s role to be a
rather passive one. In contrast, open-ended questions
invite thought, collaboration, and effort on the part of the
patient.
• Example:
“How do you feel about your smoking?”
OARS
• Affirmation:
 It is human nature to presume a negative attitude, particularly when
one’s own behaviour is coming under scrutiny.
 Acknowledging the patient’s strengths and appreciation of his or her
honesty will decrease defensiveness, increase openness, and the
likelihood of change.
 It assists in building rapport and in helping the client see themselves
In a different, more positive light.
 Facilitating the MI principle of Supporting Self-efficacy.
• Example:
“You’re telling me clearly why you’re not very concerned about your
toothbrushing and I appreciate that honesty.”
OARS
 Reflections" or reflective listening is perhaps the most crucial skill
• It has two primary purposes.
a.
By careful listening and reflective responses, the client comes to feel that the
counsellor understands the issues from their perspective.(Express Empathy).
b.
the therapist guides the client towards resolving ambivalence by a focus on
the negative aspects of the status quo and the positives of making change.
 Appropriate reflection:
• (1) captures the underlying meaning of the patient’s words,
• (2) is concise,
• (3) is spoken as an observation or a comment, and
• (4) conveys understanding rather than judgment.
• Example: “You really seem to have lost hope that you can ever really quit
smoking.”
OARS
Summarize
• Summarizing the patient demonstrates interest, organizes the
interview, and gets things back on track if necessary.
• It involves the compilation of the patient’s thoughts on change
mentioned during the counseling.
• Summaries communicate interest, understanding and call attention to
important elements of the discussion. They may be used to shift
attention Or direction and prepare the client to “move on.”
• Example: “So there’s a big part of you that doesn’t feel ready to
change right now. You really enjoy smoking, but you have been a little
worried by the way some people react when they find out that you
smoke. Is that about right?”
Change talk
• Change talk: is the patients’ expressions of desire,
reason, ability or need to make a change in their oral
health behaviours.
• Expressions of change talk may come naturally as a
result of open-ended questions and reflections or can be
further elicited through the use of directed questions.
• Response to change talk provides the opportunity to
explore options and affirm a commitment to change.
Types of Change talks (DARN-CAT)
Preparatory Change Talk
 Desire (I want to change)
 Ability (I can change)
 Reason (It’s important to change)
 Need (I should change)
Implementing Change Talk
 Commitment (I will make changes)
 Activation (I am ready, prepared, willing to change)
 Taking Steps (I am taking specific actions to change)
Evocative questions to elicit change talk
• Why would you want to make this change?
• If you did decide to make this change, how might you go about it in order to
succeed?
• What are the three best reasons for you to do it?
• How important would you say it is for you to make this change, on a scale from 0 to
10,
where 0 is not at all important, and 10 is extremely important?
Follow-up questions
• And why are you at ____ rather than a lower number of 1?
• What would it take to move you to a X (slightly higher score)?
Summarize then ask one final question
• So what do you think you’ll do?
MI strategies in delivery of Oral Health
advice
• The key components of brief MI which can be applied for
the delivery of oral health information and advice are:
1. Ask Permission,
2. Elicit Provide Elicit (using OARS),
3. Explore Options
4. Affirm Commitment.
Ask Permission
• Soliciting the patient’s permission to share information sets the
collaborative spirit of MI right from the start and provides the
patient with the autonomy to accept or decline the offer.
• Provide information when the patient is willing and interested in
receiving it.
• Practitioners commonly err by providing advice too soon in an
encounter with a patient, resulting in patients perceiving the
practitioner as having an agenda that they are trying to “push”.
• "May I ask you a few questions about your current oral
hygiene habits so I can understand your situation better?"
Elicit-Provide-Elicit
• Rollnick et al. (1999) have outlined a three-step process that serves as a useful
framework for providing advice in an MI consistent style:
Step 1: elicit the patient’s readiness and interest in hearing the information. For
example a practitioner might say to a patient “I have some information related to
smoking that you may be interested in. Would you be interested in hearing more
about that?”
Step 2: provide the information in as neutral a fashion as possible. For example, a
practitioner might say “Research indicates that. . . .” or “Many of my patients tell me
that . . .” This allows factual information to be presented in a manner that supports
the patient’s autonomy.
Step 3: elicit the patient’s reaction to the information presented. Following up will
often facilitate the patient to integrate the new information in a way that brings about
a new perspective and increases motivation to change. Alternatively, following up
may reveal further gaps in knowledge or misunderstandings that can be addressed.
Elicit-Provide-Elicit
• If a patient “rejects” the information it is important not to
get into a debate.
• It is generally better to simply acknowledge the patient’s
perspective with statements such as “This information
doesn’t fit with your experience” or “This information
doesn’t seem relevant to your situation” and then move on
to a more productive area of conversation.
Clinical Case 1 - James
Elicit
Provide
Elicit
The patient’s
readiness/interest
in hearing the information/
instruction
Solicited information or
advice in as neutral fashion
as possible
The patient’s reaction to
the information/instruction
provided
What do you know about how
long you should brush?
The data show us that patients
do have a natural tendency to
overestimate their brushing time.
Could this be true in your case?
There is another option that
might help you increase your
actual brushing time. Would you
be interested in hearing about it?
Some electric toothbrushes have
a timing device to help ensure
you brush for two minutes
Is that something you think you
might like to use at home?
Clinical Case 2: Teresa
• This video segment explores how brief MI can be used to
communicate health risks and health behaviour change to
improve oral health outcomes for a patient with Diabetes. As
expected, the clinical response and healing after quadrant
scaling and root planning in this patient with poor glycemic
control is impaired. Teresa is clearly marginalized upon being
told once again that she has failed to adequately manage her
diabetes as clearly demonstrated by the disenfranchised look
on Teresa’s face.
• During the MI segment a very effective change talk strategy
referred to as the Motivational ruler is employed. The use of
the ruler allows the clinician to affirm the patient’s current level
of importance, confidence and/or motivation to make a change
– thus acknowledging their autonomy and responsibility for
their own health.
• The use of the motivational ruler averts resistance, engages
and provides an opportunity to explore options for change.
Case example for
tobacco use cessation
Dr According to your tobacco use history, you are
currently smoking cigarettes. May I ask you a
few questions about your smoking?
P Yes.
Dr Tell me how you feel about your smoking.
P Well I know I should quit. I know it’s not
good for my health. But I don’t want to quit
right now.
Dr So you don’t feel that you want to quit right
now, but you do have some concern about the
health effects.
P Yes.
Dr Well, tell me more about what concerns
you?
P Well, mainly that I would get lung cancer or
something.
Dr So you worry a bit about getting cancer
because of smoking. Is there anything else that
you don’t like about smoking?
P Well if I quit my clothes would stop
smelling.
Dr So the smell of tobacco smoke is something
you would like to be rid of?
P Yes, but I’ve smoked for many years, you
know and I tried to quit once before.
Dr So even though you would like to be a
nonsmoker for health and other reasons you
haven’t had much success quitting.
P Yes, and right now I’m enjoying smoking so
there’s not much motivation to try.
Dr Well it sounds like even though you have
some important reasons to quit, you’re not
very confident you could succeed and you
don’t feel ready to take on this challenge right
now. I wonder if it would be OK for us to talk
about this again next time to see where you
are with it and whether I could help?
P Yes that sounds fine.
• Thank you