Stages of change model & Intervention Program_Public health pharmacyShahan Ullah
Understanding different stages of a person/patient unwilling to do a task beneficial to him/her to Keep him/her on that path for the rest of his/her life for his/her own benefit
Financial counselors and educators find themselves in a quandary. They offer their clients a wealth of information about how to overcome financial obstacles and achieve financial goals. However, clients often lack the motivation to act on this information. Good information is necessary but often insufficient to motivate action. Motivational Interviewing, or MI, provides a powerful set of tools any helping professional can use to motivate change. MI has been refined by 30 years of research resulting in over 200 published studies with a variety of populations. MI has been found effective wherever helping professionals need to motivate behavior change.
Register for webinar, find supportive materials and join the webinar here: https://learn.extension.org/events/2638
Stages of change model & Intervention Program_Public health pharmacyShahan Ullah
Understanding different stages of a person/patient unwilling to do a task beneficial to him/her to Keep him/her on that path for the rest of his/her life for his/her own benefit
Financial counselors and educators find themselves in a quandary. They offer their clients a wealth of information about how to overcome financial obstacles and achieve financial goals. However, clients often lack the motivation to act on this information. Good information is necessary but often insufficient to motivate action. Motivational Interviewing, or MI, provides a powerful set of tools any helping professional can use to motivate change. MI has been refined by 30 years of research resulting in over 200 published studies with a variety of populations. MI has been found effective wherever helping professionals need to motivate behavior change.
Register for webinar, find supportive materials and join the webinar here: https://learn.extension.org/events/2638
Guidance and Counselling for children. The basic skills which need to be mastered by a counselor to provide effective service.
Attending skills, listening skills, paying attention skills, giving responses skills, identifying problems skills and intervention skills.
Motivational Interviewing has been described as “simple but not easy”. Continued practice and coaching are key to increasing practitioners’ MI proficiency, particularly in our intentional and strategic application of the spirit and skills of MI. This immersive, practice-based session builds on the two-day introductory Motivational Interviewing workshop by guiding participants through a series of structured, scaffolded activities that directly relate to your challenging client encounters in your day-to-day work. You will leave this fun and dynamic workshop with a renewed and deeper understanding of how to enhance your clients’ motivation for change by taking your MI skills to the next level!
Learning Objectives:
At the end of this day of applied practice, you will be able to:
1. Assess your areas of MI proficiency and further development
2. Practice OARS to evoke client change talk
3. Practice OARS to respond to clients’ change talk
4. Apply strategies to respond to clients’ sustain talk and enhance motivation for change.
Krames Patient Education is the only choice for enterprise-wide patient education. In this presentation, practices will learn who Krames Patient Education is and What we can do for you.
We will review Patient-Centered Care and Patient Education; The Case for a Patient Education Investment, The Krames Differencet; Return on Investment; and Krames Solutions.
Maxime Lê is a graduate of health sciences from the University of Ottawa that has worn many hats for many roles. Chief among them is being a patient advisor for The Ottawa Hospital. Having frequently been a patient and having a passion for health and healthcare, he decided to get involved at The Ottawa Hospital to help improve care, research and advocate for patients. Maxime, while sharing his hands-on experience and insights, answered the questions that healthcare providers, researchers, or prospective patient advisors may have, such as: ''What does it mean to be a patient advisor?'', ''Why is it important?'', and ''What impact does it have?''.
The webinar was followed by an interactive question and answer session.
Nutrition To Prevent And Fight Chronic DiseaseSummit Health
This presentation discusses ways to prevent and fight inflammation that can contribute to chronic diseases such as obesity, diabetes, high blood pressure, and cardiovascular disease. The lecture will include discussion about foods and dietary practices that can help protect, restore, and maintain your health.
Everyone will experience grief at some time in their life.
Grief can accompany many forms of loss. The death of
a loved one can be the most intense grief experience;
however there are many forms of loss that can occur.
This lecture will explore how to cope and manage a
variety of losses. It will also explore how managing
grief and loss is an individual process and the role
compassion can play.
Behaviour change techniques targeting diet and physical activity in type 2 di...Health Evidence™
Health Evidence hosted a 60 minute webinar examining the behaviour change techniques (BCTs) and features of dietary and physical activity interventions associated with reducing HbA1c in people with type 2 diabetes. Click here for access to the audio recording for this webinar: https://youtu.be/Fb6_t7_TGxw
Kevin Cradock, PhD student, National University of Ireland, Galway led the session and presented findings from his recent systematic review:
Cradock K, OLaighin G, Finucane F, Gainforth H, Quinlan L, & Ginis K. (2017). Behaviour change techniques targeting both diet and physical activity in type 2 diabetes: A systematic review and meta-analysis. International Journal of Behavioral Nutrition and Physical Activity, 14(1), 18.
Changing diet and physical activity behaviour is one of the cornerstones of type 2 diabetes treatment, but changing behaviour is challenging. The objective of this study was to identify behaviour change techniques (BCTs) and intervention features of dietary and physical activity interventions for patients with type 2 diabetes that are associated with changes in HbA1c. Thirteen RCTs were identified. Diet and physical activity interventions achieved clinically significant reductions in HbA1c at three and six months, but not at 12 and 24 months. Specific BCTs and intervention features identified may inform more effective structured lifestyle intervention treatment strategies for type 2 diabetes.
We at Just for Hearts works for preventive wellness. It is very important for any organization to have healthy employees for better productivity and work performance. Unfortunately there are very few organizations available who provides complete wellness solutions. Just for Hearts is one of them which offer complete wellness solutions under one roof starting from health awareness sessions to various wellness activities by making it available in your company premises. Here are some guidelines to have successful wellness programs based on our experience of 1000 + wellness events at Pan India level till today .
The video for this presentation is available on our Youtube channel:
https://youtube.com/allceuseducation A continuing education course for this presentation can be found at https://www.allceus.com/member/cart/index/index?c=
CEs are available for this presentation at: https://www.allceus.com/member/cart/index/search?q=dbt
Unlimited Counseling CEUs for $59 https://www.allceus.com/
Specialty Certificate tracks starting at $89 https://www.allceus.com/certificate-tracks/
Live Webinars $5/hour https://www.allceus.com/live-interactive-webinars/
Patreon: https://www.patreon.com/CounselorToolbox Help us keep the videos free for everyone to learn by becoming a patron.
Pinterest: drsnipes
https://www.youtube.com/user/allceuseducation
Nurses, addiction and mental health counselors, social workers and marriage and family therapists can earn continuing education credits (CEs) for this and other course at:
View the New Harbinger Catalog and get your 25% discount on their products by entering coupon code: 1168SNIPES at check out
AllCEUs has been approved by NBCC as an Approved Continuing Education Provider, ACEP No. 6261. Programs that do not qualify for NBCC Credit are clearly identified. AllCEUs is solely responsible for all aspects of the programs.
AllCEUs is also approved as an education provider for NAADAC, the States of Florida and Texas Boards of Social Work and Mental Health/Professional Counseling, the California Consortium for Addiction Professionals and Professions. Our courses are accepted in most states through those approvals.
Guidance and Counselling for children. The basic skills which need to be mastered by a counselor to provide effective service.
Attending skills, listening skills, paying attention skills, giving responses skills, identifying problems skills and intervention skills.
Motivational Interviewing has been described as “simple but not easy”. Continued practice and coaching are key to increasing practitioners’ MI proficiency, particularly in our intentional and strategic application of the spirit and skills of MI. This immersive, practice-based session builds on the two-day introductory Motivational Interviewing workshop by guiding participants through a series of structured, scaffolded activities that directly relate to your challenging client encounters in your day-to-day work. You will leave this fun and dynamic workshop with a renewed and deeper understanding of how to enhance your clients’ motivation for change by taking your MI skills to the next level!
Learning Objectives:
At the end of this day of applied practice, you will be able to:
1. Assess your areas of MI proficiency and further development
2. Practice OARS to evoke client change talk
3. Practice OARS to respond to clients’ change talk
4. Apply strategies to respond to clients’ sustain talk and enhance motivation for change.
Krames Patient Education is the only choice for enterprise-wide patient education. In this presentation, practices will learn who Krames Patient Education is and What we can do for you.
We will review Patient-Centered Care and Patient Education; The Case for a Patient Education Investment, The Krames Differencet; Return on Investment; and Krames Solutions.
Maxime Lê is a graduate of health sciences from the University of Ottawa that has worn many hats for many roles. Chief among them is being a patient advisor for The Ottawa Hospital. Having frequently been a patient and having a passion for health and healthcare, he decided to get involved at The Ottawa Hospital to help improve care, research and advocate for patients. Maxime, while sharing his hands-on experience and insights, answered the questions that healthcare providers, researchers, or prospective patient advisors may have, such as: ''What does it mean to be a patient advisor?'', ''Why is it important?'', and ''What impact does it have?''.
The webinar was followed by an interactive question and answer session.
Nutrition To Prevent And Fight Chronic DiseaseSummit Health
This presentation discusses ways to prevent and fight inflammation that can contribute to chronic diseases such as obesity, diabetes, high blood pressure, and cardiovascular disease. The lecture will include discussion about foods and dietary practices that can help protect, restore, and maintain your health.
Everyone will experience grief at some time in their life.
Grief can accompany many forms of loss. The death of
a loved one can be the most intense grief experience;
however there are many forms of loss that can occur.
This lecture will explore how to cope and manage a
variety of losses. It will also explore how managing
grief and loss is an individual process and the role
compassion can play.
Behaviour change techniques targeting diet and physical activity in type 2 di...Health Evidence™
Health Evidence hosted a 60 minute webinar examining the behaviour change techniques (BCTs) and features of dietary and physical activity interventions associated with reducing HbA1c in people with type 2 diabetes. Click here for access to the audio recording for this webinar: https://youtu.be/Fb6_t7_TGxw
Kevin Cradock, PhD student, National University of Ireland, Galway led the session and presented findings from his recent systematic review:
Cradock K, OLaighin G, Finucane F, Gainforth H, Quinlan L, & Ginis K. (2017). Behaviour change techniques targeting both diet and physical activity in type 2 diabetes: A systematic review and meta-analysis. International Journal of Behavioral Nutrition and Physical Activity, 14(1), 18.
Changing diet and physical activity behaviour is one of the cornerstones of type 2 diabetes treatment, but changing behaviour is challenging. The objective of this study was to identify behaviour change techniques (BCTs) and intervention features of dietary and physical activity interventions for patients with type 2 diabetes that are associated with changes in HbA1c. Thirteen RCTs were identified. Diet and physical activity interventions achieved clinically significant reductions in HbA1c at three and six months, but not at 12 and 24 months. Specific BCTs and intervention features identified may inform more effective structured lifestyle intervention treatment strategies for type 2 diabetes.
We at Just for Hearts works for preventive wellness. It is very important for any organization to have healthy employees for better productivity and work performance. Unfortunately there are very few organizations available who provides complete wellness solutions. Just for Hearts is one of them which offer complete wellness solutions under one roof starting from health awareness sessions to various wellness activities by making it available in your company premises. Here are some guidelines to have successful wellness programs based on our experience of 1000 + wellness events at Pan India level till today .
The video for this presentation is available on our Youtube channel:
https://youtube.com/allceuseducation A continuing education course for this presentation can be found at https://www.allceus.com/member/cart/index/index?c=
CEs are available for this presentation at: https://www.allceus.com/member/cart/index/search?q=dbt
Unlimited Counseling CEUs for $59 https://www.allceus.com/
Specialty Certificate tracks starting at $89 https://www.allceus.com/certificate-tracks/
Live Webinars $5/hour https://www.allceus.com/live-interactive-webinars/
Patreon: https://www.patreon.com/CounselorToolbox Help us keep the videos free for everyone to learn by becoming a patron.
Pinterest: drsnipes
https://www.youtube.com/user/allceuseducation
Nurses, addiction and mental health counselors, social workers and marriage and family therapists can earn continuing education credits (CEs) for this and other course at:
View the New Harbinger Catalog and get your 25% discount on their products by entering coupon code: 1168SNIPES at check out
AllCEUs has been approved by NBCC as an Approved Continuing Education Provider, ACEP No. 6261. Programs that do not qualify for NBCC Credit are clearly identified. AllCEUs is solely responsible for all aspects of the programs.
AllCEUs is also approved as an education provider for NAADAC, the States of Florida and Texas Boards of Social Work and Mental Health/Professional Counseling, the California Consortium for Addiction Professionals and Professions. Our courses are accepted in most states through those approvals.
Detailed understanding of Motivational Enhancement Therapy for management of Substance Use Disorders with contextual inputs for Indian population and sub-culture.
Motivational Interviewing - Dr Igor Koutsenok MD, MSjames_harvey_phd
Session 1 "Motivational Interviewing Course: Assisting Patients in Making Sustainable Positive Lifestyle Changes"
Presented by Dr Igor Koutsenok MD, MS (University of California San Diego, Department of Psychiatry) on 05/06/2020 during the first session of an ISSUP virtual training on MI.
**PLEASE NOTE that video slides have been removed to reduce file size**
Presentation content and learning outcomes:
After orientation to the underlying spirit and principles of MI, practical exercises will help participants to strengthen empathy skills, recognize and elicit change talk, and roll with resistance. Research evidence will be reviewed for the efficacy of MI and for the importance of building a therapeutic relationship in clients’ outcomes. Integration of MI with other treatment modalities will be considered.
Learning outcomes:
Introduction: Motivation and behavioral change in addiction medicine
Review of the concepts of Ambivalence, Stages of change, the righting reflex, limits of persuasion.
Spirit of MI
Expressing empathy
Roadblocks to communication
Four Processes in MI
Full details: https://www.issup.net/about-issup/news/2020-05/motivational-interviewing-course
Finding Your Compass on the Path to Recovery | Veritas CollaborativeVeritas_Collaborative
Alyssa Kalata, Ph.D and Associate Clinical Director of Veritas has learned that life values are an important step when it comes to treating eating disorders and that each individual needs their own individual compass on their path to recovery. Find out more about Kalata's treatment strategies at http://veritascollaborative.com/blog/2015/12/finding-your-compass-on-the-path-to-recovery. Also, for more insights to helping those suffering of eating disorders, visit http://veritascollaborative.com/blog.
Reported measles cases for the period November 2020—October 2021 (data as of 02 December 2021).A monthly summary of the epidemiological data on selected vaccine-preventable diseases in the WHO European Region
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
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Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Novas diretrizes da OMS para os cuidados perinatais de mais qualidade
Session 5: Motivational interviewing: unlocking the patient’s own motivation
1. Assess Readiness to Change
Motivational interviewing:
unlocking the patient’s own motivation
Session 5
Acknowledgements
Obesity Canada
2. Overview – aims
• What is motivational interviewing (MI)?
• Evidence to support MI.
• Four guiding principles:
o resisting the righting reflex
o understanding and exploring the patient’s motivation
o active listening
o empowering the patient
• Case studies
3. What is motivational interviewing (MI)?
•MI is patient-centred counselling; it involves agenda-
setting, reflective listening and shared decision-
making.
•MI is the opposite of finger-wagging; the aim is to
explore the problem from the patient’s point of view.
4. MI can achieve behaviour change
•MI assumes that behaviour change is stimulated
by motivation rather than information.
•Ambivalence to change is explored, but so are the
benefits of change.
•The answers lie within our patients, not us – our
job is to unlock those answers.
5. Extensive evidence supports MI in a variety of health areas
Low-intensity MI interventions are effective in many health-related areas where
patient engagement is key to achieving long-term behaviour change.
• Alcohol, smoking and substance abuse
• Medication adherence – e.g. asthma/COPD
• Cardiovascular health, hypertension, diabetes
• Health promotion, dentistry, obesity, physical activity
• Domestic violence, family relationships, gambling
• Mental health, eating disorders
For further information, see http://www.motivationalinterviewing.org
6. The Spirit of MI – enabling responsibility to lie with the
patient rather than the doctor
MI differs from the traditional “doctor assesses, then informs
patient of the problem and solution”. Instead, it aims to:
•collaborate with the patient to understand their perspective;
•evoke – or unlock – solutions that already lie within the patient;
•recognize that a patient’s personal goals, values and aspirations
may differ from the health professional’s.
7. The four guiding principles: RULE
• Resist the “righting reflex”.
• Understand the patient’s own motivations by exploring feelings
behind why a change is wanted and what options the patient wants to
try.
• Listen – actively and with empathy.
• Empower the patient, encouraging hope and optimism.
Develop a “guiding” style rather than a “directing” style:
“How can I help you find your way?” rather
than “Go that way!”
8. The consultation – tools
• Ask open questions.
• Listen by reflecting.
• Help to weigh up pros and cons.
• Set SMART goals.
• Use a ruler “scale of 1 to 10”.
• Use hypotheticals – “What might it take for you to make
a choice to ...?”
9. Resisting the “righting reflex”
• The urge to “correct” problems that patients present to
us is very strong.
• Yet humans naturally resist persuasion, especially if they
feel ambivalent – for instance, drinkers (or teenagers!).
• Even positive changes require effort – staying put is
always easier than making a change.
• Urging a patient to do something obviously beneficial
can, paradoxically, produce more and more reasons why
the change seems impossible.
Doctor: “I suggest you …”
Patient: “Yes, but …”
“All you need
to do is …”
10. Active listening
• Key moments for active listening:
o first “golden minute”
o cues – points when the patient seems confused, anxious, disengaged or
annoyed
o moments after you ask an open question.
• Listening by reflecting – reflect back a short summary of your
understanding:
“You feel very concerned about your
weight, but you are not confident about
the approaches you’ve tried.”
• Work through ambivalence.
11. Active listening
• I should …
• I wish …
• I want to …
Help to change these phrases to:
• I will
12. Roadblocks to listening
Silence is an important part of listening. Interrupting a patient means that
they have to deal with this “roadblock” before continuing with their agenda.
Limit the following interruptions:
• agreeing/disagreeing
• instructing
• questioning
• warning
• reasoning
• sympathizing
• suggesting
• analysing/interpreting
• persuading
13. Have you heard this?
• “I can’t see why I need to change.”
• “I can see what you mean but …”
• “Just tell me what to do.”
• “I really can’t cope at all.”
14. What we can do
Be clear about expectations and minimize the risk of
misunderstandings. This will:
• demonstrate respect for patients;
• acknowledge the patient’s autonomy;
• increase engagement in treatment.
15. Listening by reflecting
• Each reflection is a short summary statement (not question) of what is
happening at that moment.
• After you reflect back what the patient means (hypothesis), the patient
then confirms or refutes the hypothesis.
“You find it hard to exercise because of your knee pain.”
– “Yes, I’m worried exercise will make it worse.”
• Acknowledge the value of what you have heard.
“You’ve given me a clear picture …”
“That has helped me understand …”
16. Listen out for “change” talk and “resistance” talk
• Change talk – where the patient volunteers ideas,
suggestions and plans about making a change.
• Resistance talk – excuses as to why solutions will
not work or comments about feeling ambivalent or
defeated.
17. Choose carefully what to reflect
• Where a patient is using change talk, reflect this back to empower the patient.
“You plan to choose smaller portions by using a smaller plate.”
• Reflect back a patient’s ambivalence or resistance talk. This can unlock “the
other side of the argument” from the patient.
“Despite your weight you feel your eating habits are quite healthy.”
– “Well, I suppose they are not that healthy – I have a weakness for cake at
teatime.”
“Your diet is mainly OK but you have some weaknesses.”
– “I might try making a fruit smoothie or a piece of toast.”
18. Help the patient (not you) to voice arguments for behaviour change
Task is to elicit change talk from patient rather than resistance talk
Desire: statement about preference for change I want to… I wish…
Ability: statement about capacity I could… I might be able to...
Reasons: specific arguments for change I would probably feel better if…
Need: statements about feeling obliged to change I ought to… I really should…
Commitment: statements about likelihood of
change
I am going to... I will…
Taking steps: statements about action This week I started… I actually went
out and…
19. The importance and confidence rulers
• Use the importance ruler to determine a patient’s level of commitment to making a proposed
change.
“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, where would you say you are?”
Use the ruler positively: “Why are you at 8, not 4?”
• Use the confidence ruler to determine how confident a patient is that they will follow through
on a proposed change.
“And how confident are you that, if you decided to make the change, you would succeed? On
the same scale from 0 to 10, where 0 is not at all confident and 10 is extremely confident, where
would you say you are?”
Use hypotheticals: “What might it take to go from a 7 to a 10?”
20. Example: using the importance and confidence rulers
“You are planning to start attending the weight management group each week. On a scale of 0 to 10, how
important is attending this group to you?”
– “Well, I’d say it’s about an 8.”
“8 tells me it is important to you, but how confident are you that you’ll make it happen? Again, use the 0 to 10
scale.”
– “Hmm, that’s trickier. I sometimes get held up in the evenings. I’d say it’s more like a 6, as I’m not sure I’ll
get there every week.”
“As you rated it as important, what might help you make it happen regularly? How could you push that 6 up to
an 8 or 9?”
– “I think I just need to be organized. I sometimes get bogged down with housework when I get home from
work, but the club meetings aren’t very long, so there’s no reason why I couldn’t do the chores after the
meeting.”
“So, because you feel it is important, you’ll do what you can to make it happen.”
–“Yes, I shall start this Wednesday.”
21. Informing
“Giving the answers” may produce little or no change in
behaviour if the patient has become …
•bewildered – too much information or delivered too quickly
•passive – glazed over, “switched off”, bored; information
seems irrelevant or too complex
•highly emotional – angry, frightened, anxious
•depressed or distracted – poor concentration due to
depression or recent events
22. Make informing effective (1)
Ask permission “May I make a suggestion?”
This emphasizes collaboration between you and lowers resistance.
Offer choices “There are several ways you could address this. Would you like me to
explain some options?”
Talk about what others
do
“In this situation other patients have found the following approach
quite helpful.”
23. Make informing effective (2)
Elicit–provide–elicit Elicit – “What would you like to know?”
Provide – give information requested.
Elicit – “What does this mean to you?”
Beware the righting reflex Avoid making patients feel scared, humiliated, ashamed, guilty,
etc. Aim to be supportive, compassionate, empathic and
inspiring.
What does this information mean
to you?
Relate what you are suggesting to the patient’s specific situation
to enable their concerns to come forward.
24. Focusing on the impact of weight on health
Question GP’s hidden agenda Patient perception
Have you sensed that your weight has
affected your joints?
What is level of understanding re
inflammatory properties of
adipose tissue?
Understanding my condition
better may help me to help
myself.
Were you aware of the link between
weight and periods? ... diabetes? ...
sleep apnoea?
Weight loss may be the best
treatment option, so I want the
patient to feel positive.
I didn’t realize the solution
may lie with me.
What things have you tried to
improve your lifestyle?
What are the lifestyle priorities for
this patient?
I might mention I gained
weight after I stopped
smoking.
We know weight can affect the safety
of doing an operation – has anyone
talked to you about this?
How can I gently broach the fact
that you are unfit for an
operation?
Understanding the health
risks can help me make the
right decision about surgery.
25. OARS summarizes the overall
approachO Open questions questions that encourage patients to think
before answering and allow a choice in how to
respond
A Affirm acknowledge patient’s efforts, strengths and
volitional choice
R Reflective listening capture patient’s meaning
S Summarize pull together what’s been said
26. Exercises: unlocking the patient’s own motivation
Split into pairs
Exercise C1: Importance and confidence rulers
Role play: try using the importance and confidence rulers to challenge
Mrs A’s sustain talk in the examples in your workbook.
Exercise C2: Reflecting back sustain talk
Read the example of how reflecting back, or restating, the patient’s
sustain talk – rather than offering your own solution – can create a
space for the patient to present their own solution.
Role play: try the examples given to see if you can unlock change talk
from the patient.
27. Your future practice
Please consider your future practice.
• How will you balance active listening and
empathy with the time constraints of a busy
practice?
• Do you have personal examples of utilizing the
various styles of motivational interviewing
(following, guiding, directing)? If so, please
discuss.
29. Can slim people have
any idea of what
fighting obesity is
really like?
Could a health professional
with obesity have credibility
in recommending weight loss
to another person?
30. Does our own shape actually matter?
• Self-help support groups run by fellow sufferers are often
the most successful formats of all – there is nothing like
personal experience to aid empathy.
• Understanding a patient’s perspective can come from
active listening – it does not necessarily need to be
experienced.
Answer – Not if our aim is to help patients explore
their own goals.
31. Group discussion questions
• What is it like living with obesity or a
chronic condition? (patient
experiences)
• Do weight bias and stigma affect
health outcomes and quality of care?
Editor's Notes
Speaker notes
In this session we will provide an overview of obesity as a chronic disease and outline causes and consequences.
Speaker notes
MI involves a quite subtle change in the way we question our patients; the aim is to elicit reasons and intentions for behaviour change from patients themselves, rather than using the more familiar approach of giving advice. Telling someone what to do does not mean that they will do it, however logical the advice or earnest our pleas to make the change.
Speaker notes
Just telling people what to do does not work. “Go and lose weight!” will not help anyone. What we want to explore is: “What is stopping you from making the change that you want to make?” Then: “Can I help you overcome that barrier?”
Speaker notes
It takes effort to make any change – even positive ones. It is easier to just tick along and put up with all the troubles around us. If we can unlock the motivation within someone, then they will be able to make use of whatever supportive information is available. But without that vital motivation to change, then any amount of information, fear, threat or encouragement will fail to induce change.
The question should be: “What do you think you can do about it?” Not: “This is what I think you ought to do about it.”
Speaker notes
MI is valuable as a technique because it is a generic skill that can be applied to any number of topics where patient motivation is key to behaviour change.
However, it is a subtle skill that requires practice because it involves stepping back from “stating the obvious” approach that we were traditionally trained to use.
This session gives an introduction to the techniques. Further experience, reading and/or training would be required to become proficient in bringing this type of approach into regular patient discussions.
Speaker notes
Without listening carefully, it is easy to imagine that our patients want the same things as we do. However, not only might our aspirations differ markedly, but the enablers and barriers that influence our choices may differ also. The variation in tolerance of poor health, symptoms, risk and uncertainty is as great as the variation in people themselves.
Very few people are aiming for “perfect”, so we should start by understanding what our patient’s concept of “something less than perfect” might be.
peaker notes
MI uses lots of acronyms!
The RULE acronym sums up how MI encourages us to stand beside our patients to understand their perspective and what goals they may feasibly wish to explore – rather than confronting them with our own wise words of advice.
We will look at each point in turn.
Speaker notes
MI has a set of “tools”. Again, some are quite subtle, and we may have already used (some of) them in other situations.
SMART goals are Specific, Measurable, Achievable, Relevant and Time-bound (or Time-limited).
Speaker notes
Traditionally, our role as health workers is simple: the patient tells us what the problem is, we tell the patient what the answer is.
Yet – particularly for behaviours that generate immediate pleasure or reward, such as eating, smoking, alcohol consumption and TV viewing – information on risk is a weak driver of behaviour change. The longer-term the gain (“if you do this now, you will benefit in 20 years’ time”), the weaker its ability to drive behaviour change.
Try telling a teenager to clean their bedroom! What lengths might a parent have to go to, to achieve compliance: bribes? threats? arguments? screaming fits? throwing things? violence? Where the gain appears small or – to a teenager – completely invisible, the chance of achieving compliance is small or remote. “If you’re so bothered, then do it yourself!”
By resisting the righting reflex – by avoiding the “if that’s the problem, then here’s the answer” type of response – we can hopefully avoid the common “Yes, but …” response, which signals the tendency to give more and more reasons why solutions won’t work.
Think about the patient’s psychology: “Not only have I had to admit I have a problem and you smugly have all the answers – but now you’re telling me I’ve got to do it your way? Not a chance!”
Speaker notes
Active listening is much more than showing that you are giving your full attention to the patient – it is a process whereby the patient is helped to listen to themselves.
The first moments (“golden minute”) of a consultation are particularly important to establish rapport, trust and set the tone of the conversation
Silence is a very important tool – allowing the patient time to convey what is important.
Pick up on cues – points of hesitation or doubt, or changes in body language, that might indicate that there is more to the story than the patient has so far conveyed.
The point of “reflecting back” a short summary of what has been said is that the patient has an opportunity to “hear” what might have been quite a jumbled accumulation of thoughts.
Speaker notes
Active listening: when you hear your patient say phrases such as “I should” and “I wish”, how can you support and encourage them to change to “I will”?
Speaker notes
Even positive and supportive comments and interruptions can interfere with the flow of the patient’s story – or prevent emergence of those points of hesitation that sometimes indicate what the real sticking points are.
Being silent can take practice!
Speaker notes
“I can’t see why I need to change”: often, when health professionals hear this statement, they assume that the patient is in denial. It is important to reflect on this, however, because the literature suggests that health professionals do tend to assume that the patient is in denial. They have an unproductive tendency to blame the patient, but it is important to bear in mind that denial is a response that people have when they feel under pressure – it is a natural human tendency.
“I can see what you mean but …”: this may indicate that the patient is not sure about making a change. This suggests that there may be an opportunity to explore the area a bit more with the patient.
“Just tell me what to do”: traditionally, people have the expectation that we are the experts and that we should be telling them what they should be doing. Sometimes, this can be appropriate in the context of a therapeutic relationship, but again it is always important to ask: “But how would that work for you?”
“I really can’t cope at all”: this is a red flag indicating that the individual is feeling overwhelmed, so it is important to step back and see where the place of readiness is. Maybe the patient is not ready to embark on a particular stage? What is going on in their lives? Are there lots of barriers in their lives?
Speaker notes
Be clear about our roles and expectations of what services we can and cannot provide.
A patient often arrives with traditional expectations about receiving some kind of treatment, but it is important to clarify that treatment involves lifestyle modification/behaviour change and requires their active participation.
Speaker notes
The first benefit of listening by reflecting is the chance to reflect back summary statements – not questions – that the patient can then either agree with or correct. This enables the patient to expand on their concern – to get to the nub of the problem.
So:
First, the patient has given an unstructured outline of the problem.
Second, you have pulled together a summary statement of the main issue.
Third, the patient has agreed that this sums up the main issue and expanded on why this is important; or the patient realizes that this is not exactly what the concern is and is able to correct the focus of the discussion.
For example:
Reflection: “You find it hard to exercise because of your knee pain.”
Response: “Well, no, not my knee pain exactly. All my joints hurt in fact. I suppose what I am really worried about is that exercise might cause a heart attack – that’s what happened to my father. I think the knee pain just gives me an excuse not to do too much.”
Speaker notes
Reflecting back change talk is a good way to endorse your patient’s commitment to change.
“You are going to alter your routine by parking in a more distant carpark and walking a bit further to your office.”
This invites agreement – and perhaps embellishment – from the patient.
“Yes, I think a bit of fresh air might perk me up for the day.”
But an even bigger benefit of listening by reflecting is the ability to reflect back ambivalence or resistance talk. This helps patients to “hear themselves”, which then encourages them to respond to their own suggestion rather than responding to yours. Instead of saying “Yes, but …” to your constructive suggestion, they are saying “Yes, but …” to their own ambivalence.
Speaker notes
In order to elicit these sorts of response, we can see that our aim is to ask the patient for ideas – rather than simply giving the information ourselves.
Hence, in response to your statement “We know that being active is beneficial for arthritis”, rather than continuing with obvious suggestions such as “I would recommend that you try to walk more/join a dance club/try swimming”, try prompting the patient to provide suggestions:
“We know that being active is beneficial for arthritis …
… How important does physical activity feel to you?”
… How feasible would it be for you to be more active?”
… Is physical activity something you have considered?”
Speaker notes
Assessing importance is one of the key factors when homing in on motivation. We are simply not going to make a big effort to achieve things that don’t seem important.
Use the importance ruler to build commitment to suggested changes. By reflecting the patient’s stated view of its importance, and then double-checking by assessing how confident they are that it will happen, you are confirming the degree to which the patient has signed up to this change.
Speaker notes
You could read out this case scenario with someone else playing the part of the patient.
Speaker notes
Sometimes, despite our best consultation skills, the conversation does not seem to flow. Why not?
Consider whether any of the factors listed here might apply to your patient.
Depression will commonly affect concentration and confidence in setting personal goals. Is weight management the top priority right now? Sometimes it is better to put the topic on hold and come back to it when the patient feels in the right frame of mind.
Speaker notes
Rather than “giving the answers”, we are aiming to elicit patient-generated answers. But what if the patient has drawn a blank and really does not know what to suggest?
Informing then becomes relevant and helpful – as long as we do not create the “Yes, but …” scenario.
The suggestions here can help you arm the patient with ideas that they can pick up and run with.
(Analogy: instead of dressing the person, you are showing them a wardrobe for them to choose what to wear.)
Use of the third person “People find that …” rather than the first person “You could/should …” – this makes it less likely that the “Yes, but …” response materializes.
Sensing that there is a choice is always a good starter for engagement. But importantly, the conversation should progress to exploring those choices in order to commit to a decision. “There are lots of things you could do. Shall we explore what are you actually going to do?”
Speaker notes
One way to explore how the patient is weighing up the suggestions you have mentioned is to use the elicit–provide–elicit concept. Double-check after setting out your suggestions: “What does this mean to you?”
Remind yourself to avoid emotive reasons for change.
Consider the individual circumstances that your patient is in, especially when exploring confidence and feasibility of the suggested changes. For example, might childcare needs, working patterns, transport issues, financial constraints or disability limitations have an impact on the feasibility of some potential choices?
Speaker notes
One of the reasons you may be discussing weight or activity levels is because of the presenting condition of your patient. It may be important to discuss that weight control or increased activity might improve their condition.
Ensure that factual information is provided without burdening the patient with a sense of guilt or blame for their condition. Use the third person to convey facts and explain links between conditions: “People with diabetes will find that …” “Studies show that …”
Discussing the relevance of a person’s weight to their anaesthetic risk or benefit from potential surgery (e.g. knee replacement) may be very valuable in helping the patient to understand the risks involved and to get a sense of how they can personally take steps to reduce that risk by improving health pre-operatively.
Speaker notes
This acronym neatly sums up the approach.
Remember that silence is a valuable tool.
Check out how important change is and explore what degree of confidence the patient has in achieving it.
Use reflective listening both to show that you are listening and to help the patient listen to their own viewpoint.
Pull the discussion together by affirming the intentions the patient has suggested.
Speaker notes
Speaker notes
Speaker notes
This is recognized as an increasingly important issue.
Health workers share roughly the same weight range statistics as the rest of the population, which means that a significant number of health professionals are overweight or obese.
Speaker notes
Ask the group for their views.
Ask for a show of hands:
Who thinks that an obese health worker would find it difficult to give credible weight management advice?
Who thinks that slim health workers have a bit of a nerve telling overweight patients how to live?
Speaker notes
If we were out to lecture or wag a finger at our patients, then we could expect trouble!
However, far from wishing to confront our patients, an effective conversation involves walking alongside our patients to see their viewpoint, trying to understand their issues from their perspective and doing what we can to help them find their way.
Acknowledging our own weight may be helpful and does not require anything more than a glancing comment to convey a shared understanding. Examples might include: “I know just how it feels”; “You can see I am fighting the same thing”; “It’s a real struggle, I know”.
To move the conversation straight back to the patient, and away from the health professional, ask about importance. “How important is your weight to you at the moment?”
Speaker notes
Explore the group’s views on these questions.
Living with obesity. Consider:
furniture – e.g. hospital bed size has increased, now catering for patients weighing up to 285 kg (previously around 150 kg)
transport
bullying
work opportunities
daily symptoms – breathlessness, pain, hunger, sense of shame, depression
Weight bias and health care. Consider:
blame
rudeness
disgust
pity
lack of understanding
rationing of health care due to weight
How can we address this?