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Motivational Interviewing, Stages of Change, and Bay Pines Resources for Smoking Cessation

By: Beth Williamson, RN-Student, University of South Florida

Why Is Smoking Cessation Counseling Important?

American deaths from tobacco annually
Equal to American deaths in WWII 12 times deaths in Korean War 8 times deaths in Vietnam War 75 times deaths in OIF/OEF 20% all deaths 3,000 deaths from secondhand smoke 1,000 fetal and infant deaths from smoking during pregnancy

Veterans and tobacco

33% veterans overall use tobacco 45% young veterans use tobacco 16.7% veterans over 65 use tobacco

6 million years in potential lost life $80 billion health care costs Nicotine addiction is worse than addiction to cocaine or heroin

Quitting Tobacco
70% smokers report wanting to quit, and most have made at least one quit attempt As little as 3 minutes of counseling doubles quit attempts and successes Ask about tobacco use at every visit!

What is Motivational Interviewing?

A client-centered counseling style to help elicit behavior changes Respects the autonomy of patients, while the provider helps elicit patients intrinsic resources for change Provider is facilitator rather than expert, nonconfrontational approach Elicit reasons for change from patient, not advising them why they should change

Basic MI Techniques
Open-ended questions- Tell me about What have you tried before Affirmations- Recognition for patients strengths; I appreciate you being open with me today That is a good suggestion Reflections- Provider clarifies what patient is saying; It sounds like you are saying Youre wondering if Summarizing Helps reinforce understanding between patient and provider; Let me see if I understand so far End with Did I miss anything? Identify discrepancies- Between patients goals and current behaviors; What do you feel you need to change to meet your goals? Role with resistance- Encourage patients to come up with their own solutions; if you meet resistance, it s a telltale sign to respond differently; How do you want to proceed? Support self-efficacy- Help patient believe change is both possible and attainable; You have a good plan of action Always ask permission before giving information- Would it be okay if I explained some benefits of stopping smoking? Assess confidence- Recall times in past when patient has made successful achievements, set small reachable goals; On as scale of 0-10

Resist the righting reflex- Resist the urge to tell the patient to follow the path of good health Understand the patients own motivations- Guides further discussions and helps practitioner understand potential barriers Listen with empathy- Equal amounts of time listening and talking; understand, acknowledge, and value what patient is saying to you; You seem pretty frustrated It sounds like deciding to take that first step is scary for you Empower the patient- Empower patient to explore own ideas about how change is possible and BELIEVE IN THE PATIENT

What not to do
Judgmental and leading talk- You dont smoke do you? Close-ended questions Advice giving Directions Confronting resistance Asking for feeling states Shoulds

Stages of Change

Person is uninterested, unaware, or unwilling to make a change What to do:
Develop rapport with patient Acknowledge and validate their feelings and beliefs Reframe patients comments in a positive way Discuss medical benefits of quitting smoking Invite patient back

Person is considering making a change What to do:
Reinforce reasons to change Explore pros and cons of continuing to smoke Find out whats important to the patient Connect how smoking effects these important things with patient Encourage autonomy- Emphasize change is up to patient Encourage self-efficacy- Increase patients confidence that he can change

Person is deciding and preparing to make a change What to do:
Praise patient about being ready to make a change Problem solve- Make a plan, set priorities, examine barriers, set social supports Maintain patients autonomy

Person is actively practicing change behaviors What to do:
Support current behaviors Acknowledge difficulties Educate patient Plan for high risk situations Help patient find support through groups, community, outpatient therapy, etc.

Person is attempting to maintain new behavior over time What to do:
Review benefits of smoking cessation Continue to praise Help with problem solving Identify triggers Support lifestyle changes and healthy coping skills

Barriers in Practice
Time constraints Professional development required in order to master MI Difficulty in adopting the spirit of MI when practitioners embody an expert role Patients' overwhelming desire for 'quick fix' options to health issues Patient noncompliance with medical regimens Adopting MI takes commitment, practice, and time, but can yield great results and can increase your confidence and satisfaction in your patient care techniques!

What else MI can be used for

Medication adherence Management of chronic diseases such as diabetes or heart failure Management of other substance abuse problems Management of gambling and sexual risk taking behaviors Pain management Stress management Completion of health referrals and diagnostic tests

Smoking Cessation Resources at Bay Pines

Smoking cessation group classes
8 week program- Classes on Thursdays, 4 time slots, 1 hour long Referred by physician, nurse practitioner, or nurse (see following slides on how to initiate consult) Set quit date on week 4 of class Review nicotine replacement therapy and other pharmacotherapy options, veterans able to order these at meeting with nurse practitioner if wanted Veterans learn how to change habitual behaviors and cognitive pattern, learn new coping mechanisms Able to bring spouse or family members who want to quit smoking to class, even if not veteran

Step 1: In Outpatient Consult Menu click on HPDP Health Promotion Disease Prevention

Step 2: Under Tobacco Free Program click on Tobacco Free Menu

Step 3: Under Orders click on Tobacco Free Program [Bay Pines]

Step 4: Select Preferred Thursday time and location and add patients Current telephone number

Step 5: If nurse placed consult, physician can Accept Order

After Order Placed

Staff member who organizes class schedules will contact patient via telephone, mail, or both to confirm interest in class and scheduled time/start date

Tobacco Cessation Resources at Bay Pines Continued

Nicotine replacement therapy and other pharmacotherapy methods- ordered by physician or nurse practitioner, but nurse can discuss uses and benefits with patient

Efficacy of Medications for Smoking Cessation

% Abstinence at 6 Months 40 35 30 25 20 13.8 15 10 5 0 33.2

28.9 29.9






Type of Medication Used

Source: HIV Provider Smoking Cessation Handbook, a Resource for Providers, 2012

Tobacco Cessation Resources at Bay Pines Continued

Relapse prevention program- Group class run by veterans to help those who have already stopped using tobacco remain tobacco free (contact Dr. Roma Palcan for more information- contact information on References slide) Online smoking cessation program in works- Will follow same format as live classes, but veterans (and VA staff) can conveniently access program from home Strict regulations on smoking areas at Bay Pines- If you see veterans or staff smoking in non-smoking areas on campus, kindly remind them of the nearest smoking area (see link for designated smoking areas map on References slide)

Role Play 1
Patient: A 35 year old male who is at primary care clinic for annual physical. During initial visit with nurse, patient states he uses tobacco. Nurse: Just discovered that patient uses tobacco. Uses motivational interviewing techniques to examine smoking behaviors, identify stage of change patient is in, and counsels accordingly.

Role Play 2
Patient: A 66 year old male who is at primary care clinic for acute pain in back. During initial visit with nurse, patient states he uses tobacco. Nurse: Just discovered that patient uses tobacco. Uses motivational interviewing techniques to examine smoking behaviors, identify stage of change patient is in, and counsels accordingly.

Motivational interviewing resources
Hall, K., Gibbie, T., & Lubman, D. I. (2012). Motivational interviewing techniques: Facilitating behavior change in the general practice setting. Australian Family Physician, 41(9), 660-667. http://www.slideshare.net/parksrn/mi-workshop http://www.smartrecovery.org/resources/UsingMIinSR.pdf http://www.motivationalinterview.org/index.html

Bay Pines resources

Dr. Roma Palcan- Coordinator of smoking cessation program
Extension 7849 Roma.Palcan@va.gov

General questions regarding smoking cessation classes

Extension 5206

Map of designated smoking areas http://www.baypines.va.gov/BAYPINES/TobaccoFree/Images/CampusMap_Be TobaccoFree.jpg