Train the Trainer: Home Care Chronic Disease Prevention for CNAs A collaboration of Duke University, Division of Community Health and University of South Carolina School of Medicine

1
Train the TrainerHome CareChronic Disease
Prevention for CNAsA collaboration of Duke
University, Division of Community Health and
University of South Carolina School of Medicine

• Melanie Bunn, RN, MS

2
Objectives

• Identify potential impact of home care aides on
  client outcomes
• Demonstrate motivational interviewing strategies
• Discuss use of adult learning principles,
  multiple intelligences and experiential learning
  model
• Describe strategies for integrating curriculum
  into current systems of care and training

3
Purpose of the program

• Increase home care aides understanding of common
  chronic diseases
• Introduce motivational interviewing as a strategy
  to improve client compliance with lifestyle
  choices
• Improve personal lifestyle choices of home care
  aides

4
Structure

• Nine 1.5 to 2 hour sessions
• Health and Illness
• Motivational Interviewing
• End of Life

• Chronic disease modules
• Myocardial Infarction
• Chronic Obstructive Pulmonary Disease
• Diabetes
• Hypertension
• Congestive Heart Failure
• Cerebral Vascular Accident

5
Outcomes of pilot program

• 2 NC cohorts

• 4 SC cohorts

• 41 first day
• 34 completers
• 78 female
• 94 Africa American, Black, African
• 3 White
• 3 Other
• 48.5 with chronic health problems

• 60 first day participants
• 42 completers
• 100 female
• 63 African American, Black, African
• 33 White
• 3.6 Other
• 29.8 with chronic health problems

6
Outcomes of pilot

• Improvement in disease management knowledge
• Improvement in communication between CNAs and
  patients
• Increased belief in the importance of self-care
  and lifestyle choices
• For patients and self

7
Subjective responses

• Listening better to their patients
• Being more empathetic
• Talking with patients about healthy eating and
  encouraging them to take their medications
• This has really changed my life. I have been a
  CNA for almost 30 years. This class is different
  from any other I have been to because it not only
  teaches you how to take care of the patient, it
  teaches you how to take care of yourself.

8
Impact of Home Care Aides

• Objective 1
• Content from Module 1
• Health and Illness

9
Whats the role?

• Focus is on their potential contributions in the
  situation of dealing with changes in home clients
• Reinforced throughout each module

10
Managing change

• The home care aide may be the first person to
  notice changes in the client
• Their responses may make the difference between
• Hospitalization and home management
• Suffering or comfort
• Life or death

11
4 steps to dealing with changes

• Step 1 Watch for changes
• Step 2 Gather information
• Step 3 Report what youve found
• Step 4 Document your findings

12
Step 1 Watch for changes

• Small changes may mean big problems.
• Older people and people with several health
  problems have more trouble recovering from
  illness.
• SOthey get sicker faster
• ANDtake longer to recover
• The sooner we notice something wrong-
• The sooner we can start to fix it
• The more likely we are to get a better recovery.

13
Atypical symptoms and signs

• Often older people dont respond to being sick
  the way younger people do.
• First sign of a problem might be confusion or
  behavioral changes
• Vital signs might not change
• They might not complain of symptoms
• The symptoms they do tell you about might be
  vague (worn out)

14
Kinds of changes to look for

• Anything that is different for this client
• Anything out of normal limits
• Physical
• Functional abilities
• Routine changes
• Thinking problems
• Emotions
• Behaviors

15
STEP 2 Gather information

• When, where, how long, how often, how bad
• Use your senses
• Look
• Listen
• Touch
• Smell
• Instincts

16
Trust your instincts

• If you think or feel something is wrong,
• but just cant put your finger on it,
• ask for help!

17
Step 3 Report what youve found

• Be specific
• What do you see, hear, feel or smell?
• Describe - dont label the problem
• Explain why youre concerned
• How is this different from normal?
• Behave professionally
• Treat people like you want to be treated
• Try to understand other peoples situations

18
Step 4 Record what you found and what you did

• Symptoms
• What did the person say?
• Signs
• What did you see/hear/feel/smell?
• Who did you tell?
• What did you do?
• What was the response?

19
Lets try it!!!
20
Motivational InterviewingSo, you want to help
people change from unhealthy to healthy lifestyle
choices

• Objective 2
• From Module 2
• Motivational Interviewing

21
What health behaviors do people say they want to
change?

• Stop smoking
• Get more exercise, physical activity
• Improve their diets, nutrition
• Lose weight
• Stop/reduce alcohol use
• Take medications correctly

22
Why do people change their health behaviors?

• Fear of consequences
• Fear of loss
• Finances
• Relationships
• Health

23
Why do people not change?

• Fear of failure
• Lack of support
• Lack of knowledge about why change is important
• Lack of confidence in ability to change

24
Opening the discussion

• How can we help our clients not only change
• but change because they want to change,
• not because someone else wants them to change?

25
A new way of helpingmotivational interviewing!

• First
• NEVER give medical advice
• Then
• Be a role model by making healthy choices
  yourself
• And remember
• All information is confidential/based on agency
  requirements

26
Motivational Interviewing

• Client centered, directive method to help people
  become motivated to change
• FIRST Find out what is important to the client
• THEN Use this to motivate the client to change
• A method to help people change for themselves

27
General points

• Start by establishing rapport and trust
• Promote motivation by asking open ended questions
  that allow the client to
• Discover for themselves the reasons for their
  habits
• Discover what is important to them
• Give suggestions only when asked and as
  infrequently as possible

28
General points

• Avoid arguing, even when you strongly disagree
  with a clients reason for having a habit
• Realize that clients will be at different stages
  of being ready to change accept the clients
  level of readiness for making a change this
  timeGo WITH the resistance!
• Avoid being judgmental accept the clients
  reasons for not making a change in their habits
• People change because they want to NOT because
  you want them to

29
Motivation to change

• Knowledge alone does not usually lead to change
• People also need to become motivated to change

30
Getting started

• The first step is to create a partnership
• Trustful partnerships are created by
• Listening
• Asking questions

31
Listening

• What makes a good listener?
• Body language
• Sit forward
• Nod
• Do not do other activities at the same time
• Make eye contact
• Do not interrupt
• Do not judge

32
How to listen

• Clarify ? could you explain that more
• Restate? what you are saying is.
• Remain neutral ? nod, uh- huh..
• Reflect ? it sounds like.
• Summarize ? if I understand correctly..
• Adapted from HIP, CHA training, 2005

33
Two kinds of questions

• Closed ended questions
• Open ended questions
• A key to effective MI is getting the client to
  think more deeply about the effects of their
  health behaviors.
• This can be done by asking open ended questions.

34
Questions not to ask

• Why dont you want to change?
• How can you think you dont have a problem?
• What makes you think you are not at risk?
• WHY are these bad questions?

35
Stages of change

• Willing
• Able
• Ready

36
Willing

• Do you want to change? Why?
• What do you want to change?
• How important is it to you to change?
• Are you happy where you are? OR
• Are you torn between wanting to change and
  staying the same (on the fence)? OR
• Is your desire to change strong enough for you to
  start taking action?

37
Able

• Do you have what it takes to change?
• Ability?
• Confidence?
• Can you overcome the barriers and setbacks that
  can make it difficult to change?

38
Ready

• If you are willing and able
• How will you do it? Do you have a plan?
• Can you troubleshoot as your plan unfolds?
• Are you prepared with alternate plans if barriers
  and obstacles arise that can cause setbacks?
• Are you prepared to monitor your progress?

39
Willing How motivated are you to change?

• This exercise helps you more clearly define all
  the reasons you have for
• Not changing your resistance to change and
• Changing your motivation to change
• In this exercise you will answer some questions
  that will help you fill out a chart called a
  Decision Balance Chart

40
Decision Balance Chart

• Look at your Decision Balance handout
• On the left side, youll answer questions that
  will help you become more aware of the reasons
  you have for not changing.
• On the right side, youll answer questions that
  will help you become more aware of the reasons
  you have for changing.

41
Decision Balance Chart

• Write down one of the health behaviors you wrote
  down at the beginning of the class
• Your answers on the Decision Balance chart will
  inform you on how motivated you are to achieve
  this goal
• Or stated another way
• The balance between the left side and the right
  side will tell you how WILLING (motivated) you
  are to change.

42

• How WILLING Am I to Make the Change Needed to
  Achieve My Goal?
• Behavior

Reasons I have for Not Changing Reasons I have for Changing
What benefits am I getting by staying the same, not changing? What are my fears about changing? What is the worst outcome I can imagine if I dont change? What would my life be like if a miracle happened and I was able to change tomorrow (benefits of change)?
43
How WILLING are You to Change?

• Consider the importance you give to your reasons
  for not changing and to your reasons for changing
• Compare these and use the Ruler of Change to
  score how important making a change is to you.
• On a scale of 0 to 10, how important is it to you
  to make a change?

0 1 2 3 4 5 6 7 8 9 10
Very weak Very Strong
44
Are you WILLING?

• Three possibilities
• 1. No, score 0-3
• 2. On the fence, 4-6
• 3. YES, score 7-10

45
Are your reasons for staying the same stronger
than your reasons for changing?

• If so (score 0-3), youre not quite willing to
  change.
• How can you help someone who is not thinking
  about change?
• Help them increase their motivation and/or
  decrease their resistance so they start thinking
  more about making a change
• Ask,
• What would it take to reduce your reasons for
  staying the same?
• What would it take for you to increase your
  reasons for changing?

46
Are your reasons for staying the same about the
same as your reasons for changing?

• If so (score 4-6), you are thinking about change
  but are split between taking action and staying
  the same
• When youre on the fence like this, its hard to
  take action
• How can you help someone who on the fence?
• Ask questions to help them increase their
  motivation and/or decrease their resistance so
  they can get over the fence to the side of taking
  action

47
Are your reasons for changing greater than your
reasons for staying the same ?

• If so (score 7-10), you are not only thinking
  about making a change but you are willing to
  prepare and take some action to make a change.
• How can you help someone who is ready to take
  action?
• Help the client make a good plan so they are more
  likely to achieve their goal
• The plan should be Specific, Measurable, Action
  oriented, Realistic, and has a Time frame for
  completion.

48
ABLE - Assessing your confidence and ability to
achieve your goal

• Understanding your confidence and ability can
  help you
• Redefine your goals if your sense of confidence
  and ability is low (such as, start with smaller
  goals)
• Start thinking about what it would take to
  increase your confidence or your ability to
  change.

49
ABLE Confidence and Ability

• Score your confidence, from 1 to 10, to make a
  change
• Score your ability to make change.

0 1 2 3 4 5 6 7 8 9 10
None Low Medium Very High
0 1 2 3 4 5 6 7 8 9 10
None Low Medium Very High
50
Increasing your confidence and ability to change

• Increase your success by asking questions
  evoking change talk
• Ask yourself,
• What would it take to increase my confidence to
  make this change (the change being eating
  smarter, moving more, stop smoking, etc)?
• Ask yourself,
• What would it take to increase my ability to
  make this change?

51
Optimism about change

• The client has high confidence and a high sense
  of their ability to make the change
• He/she is more likely to make the change!!!
• Positive external supports can help increase
  confidence and/or ability.
• Ask questions that can uncover these supports.
• Adapted from Miller and Rollnick, Motivational
  Interviewing, 2002

52
Optimism about change

• Questions that help you define the supports most
  important to your client.
• What encourages you to believe that you can
  change?
• What else would help you change?
• Who else would help you change?
• You are one of the most important supports
• You can give the client a higher sense of
  confidence and ability and encourage their
  optimism.

53
Ready

• Setting goals and making plans for action
• Being prepared for dealing with setbacks
• Monitoring progress

54
Set and plan a goal SMART method

• If you use the SMART method to set your goals, it
  will increase the chances that you will achieve
  them .
• Specific
• Measurable
• Action oriented
• Realistic
• Timely

55
Set and plan a goal SMART method

• Write down your personal goal in a way that
  incorporates all these elements of a SMART goal.
• Use Worksheet to record your SMART goal
• Specific
• Measurable
• Action Oriented
• Realistic
• Time

56
Ready Dealing with barriers and setbacks

• After taking action and beginning to change a
  habit, setbacks will occur
• Lapses and relapses are natural parts of the
  change process
• The key to staying motivated is to view setbacks
  as learning experiences, not failures
• And to have a Plan B

57
Ready Dealing with barriers and setbacks

• A Progress Check can be helpful in identifying
  setbacks and learning from them
• Include tracking progress in a written log or on
  a calendar
• Seeing progress helps build confidence
• Adding comments can also identify what helped,
  what was difficult, what you learned and how you
  can do better

58
Ready - Progress check

• My goal was_____________
• I was______ successful in reaching my goal
• What helped______________
• ______________was difficult
• I learned that__________________
• Adapted from HIP CHA training, 2005

59
Set and plan a goal your reward

• Reward Yourself
• A reward to yourself when you complete a goal
  provides an incentive to stay motivated.
• After I do this, Ill

60
Lets try it!!!
61
References and for more information

• HIP CHA training, 2005
• Miller, W.R. and Rollnick, S. Motivational
  Interviewing. New York Guilford Press, 2002
• William R. Miller

62
Adult Learning PrinciplesMultiple
IntelligencesExperiential Learning Process

• Objective 3

63
Adult Learning Principles

• Adult learners
• are self directed
• have knowledge and experience
• are goal-oriented
• need relevance
• are practical
• need to be shown respect

64
Using Adult Learning Principles

• Motivation
• Feel of the learning environment (open, friendly,
  low stress)
• Level of difficulty
• Reinforcement
• Retention
• Transference
• Associated, similar, understandable, beneficial

65
Lets try it!!!
66
Multiple Intelligences key ideas

• All people have potential to learn in all ways.
• Most people can become more comfortable with any
  way of learning.
• The intelligences work together to promote
  learning.
• There are different skill sets within each
  intelligence.

67

• All students (people)
• can learn
• and succeed,
• but not all
• on the same day
• in the same way.
• William G. Spady

68
Multiple Intelligences(Gardner Lazear)

• Verbal/Linguistic
• Spatial/Visual
• Logical/Mathematical
• Musical/Rhythmical
• Bodily/Kinesthetic

• Interpersonal
• Intrapersonal
• Naturalistic
• Other possibilities
• Existential/Spiritual
• Moral

69
How to use Multiple Intelligences

• Most people are strong in 3
• But not necessarily all components
• This is the most natural way to learn
• New information
• Difficult information
• Information thats not consistent with your
  strengths
• When youre stressed

70
Verbal/Linguistic learning

• Focus on words
• Enjoy reading, writing, stories, word games
• Teaching strategies
• Handouts
• Case studies
• Discussion

71
How can you tell?Verbal/Linguistic learning

• Write well
• Spell well
• Enjoy reading
• Good vocabulary

• Remember names
• Tell stories
• Talk to communicate
• Like word games, puns

72
Spatial/Visual learning

• Focus on images
• Enjoy drawing, pictures and movies
• Teaching strategies
• Pictures
• Short videos
• Graphics

73
How can you tell?Spatial/Visual learning

• Read maps/charts
• Doodle or draw
• Like movies/slides
• Like 3-D

• Like puzzles, games
• Good with packing/organizing stuff
• Good sense of direction

74
Logical/Mathematical learning

• Focus on thinking
• Enjoy reasoning, questioning, calculating
• Teaching strategies
• Charts
• Open ended questions
• Experiments

75
How can you tell?Logical/Mathematical learning

• Ask questions
• Good in math
• Play games of strategy
• Enjoy puzzles or brain teasers

• Tend to group items
• Like experiments
• Think abstractly
• Understand cause and effect

76
Musical/Rhythmical learning

• Focus on rhythm
• Enjoy music, singing, rhythms
• Teaching strategies
• Poems
• Songs
• Rhymes

77
How can you tell?Musical/Rhythmical learning

• Musical (on/off key)
• Sing/play instrument
• Listen to music
• Remember music

• Hum
• Move in rhythmical way
• Tap
• Aware of noises

78
Bodily/Kinesthetic learning

• Focus on movement
• Enjoy touch movement
• Teaching strategies
• Practice
• Role play

79
How can you tell?Bodily/Kinesthetic learning

• Athletic
• Fidget
• Mimic
• Take notes

• Handle equipment
• Good with their hands
• Move around (gross or fine)

80
Interpersonal learning

• Focus on communication
• Enjoy talking and sharing with others
• Teaching strategies
• Group activities
• Discussion

81
How can you tell?Interpersonal learning

• Social
• Leaders
• Belong to groups
• Empathetic

• Work well in groups
• Talk in class
• Compare what they understand with others

82
Intrapersonal learning

• Focus on reflection
• Enjoy thinking to self
• Teaching strategies
• Independent projects
• Journaling
• Silence

83
How can you tell?Intrapersonal learning

• Independent
• Study/work alone
• Individualistic

• May seem to faze out and get behind
• Distracted by others

84
Naturalistic learning

• Focus on patterns and classifications
• Often enjoy nature
• Teaching strategies
• Organize content in groups
• Use examples involving nature

85
How can you tell?Naturalistic learning

• Notice subtle variations in patterns
• Like to organize and find similarities and
  differences

• Like to be outside or in natural environment
• Ecological interests

86
Multiple Intelligences in adults

• Use of intelligences may change
• With age
• With intention and practice
• With cultural preferences
• Within work/learning environments
• Still, learning in a comfortable way will give
  the best results learning that will stick and
  that can be used and useful.

87
Using Multiple Intelligences

• Know your own preferences
• Identify the types of learners you work with
• Integrate strategies to meet the needs of all
  intelligences

88
Using Multiple Intelligences in teaching/training

• Integrate the intelligences into the process of
  learning, not as a distraction or ice breaker or
  entertainment
• Example hand under hand IS bodily learningstand
  up and stretch is not
• NOWlets think about how YOU teach

89
What do you do when things arent working with a
learner?

• Think about your style
• Think about the learners style
• Ask the learner whats worked in the past
• Consult with a colleague with a different
  intelligence

90
Multiple Intelligences

• Its not if youre smart
• Its how youre smart

91
Lets try it!!!
92
Experiential Learning Cycle

• Experiencing
• Publishing
• Processing
• Generalizing
• Applying
• Experiencing

93
Experiencing/Doing

• Start by
• DOING SOMETHING!
• Participating
• Practicing
• Physically trying

94
Publishing/Talking

• Share reactions and observations
• Talking
• Thinking
• Describing how, what
• What happened?
• How did you respond?
• How did that feel for you?
• What was easy/hard?

95
Processing/Understanding

• Patterns
• Discussion of why
• Describe relationships
• Why do you think that happened?
• How would this impact outcomes?

96
Generalizing/Finding bigger meaning

• Relate experience to theories
• Teaching
• Underlying expertise and knowledge
• Examples from experience
• Case examples

97
Applying/Making changes

• Plan for changes to practice
• Reflecting on how the information can be applied
  in clinical environment
• Connecting what you know with what you do
• How will you change your behavior/ practice?

98
Processing questions

• What happened?
• How did you feel?
• Do you think others might have similar responses?
• How does this relate to what you know?
• How can this change your practice?

99
Experiencing
Applying
Publishing
Generalizing
Processing
100
Lets try it!!!
101
For more information

• Adult Learning Principles
• Malcolm Knowles
• Multiple Intelligences
• Howard Gardner
• David Lazear
• www.surfaquarium.com/MI/inventory
• self assessment
• Experiential Learning Cycle
• David Kolb
• J. William Pfeiffer

102
Integrating curriculum into current systems of
care and training

• Objective 4

103
How was the curriculum developed?

• Adult Learning Principles
• Expectation of expertise with opportunities to
  share personal knowledge and experience
• Focus on why this change and why for this person
• Multiple Intelligences
• Design of sessions and modules
• Activities and time for practice
• Experiential Learning Cycle
• Sample questions to help debrief activities

104
Using the curriculum The big picture

• PRACTICE and be willing to teach out of your
  comfort zone
• Create a positive learning environment
• Do the modules as designed (use the activities)

• Emphasize practice and homework
• Adapt based on response of the learners
• Dont become a talking head
• Come up with your own ideas and share with others

105
Using the curriculum Logistics9 modules

• 2 set the stage
• Should be completed first
• Health and Illness
• Motivational Interviewing

• 7 are self contained
• End of life
• Myocardial infarction
• COPD
• CVA
• HTN
• DB
• CHF

106
How to offer the sessions

• Frequency
• Twice a week
• Once a week
• Twice a month
• Once a month
• Provide time between sessions for homework and
  practice

• Offer when people can come and learn
• Lunch and learn
• Beginning or end of day
• Length
• 90 minute sessions
• 2 hour sessions

107
Suggestions for using the modules

• If you have a contained group and can control
  attendance
• Consider focusing on a different aspect of
  motivational interviewing for each of the 7
  modules
• If you do not have a contained group and cannot
  control attendance
• Offer broad use of motivational interviewing in
  each of the 7 modules

108
What do you have available to you?

• Copies of power point slides with notes and
  comments (available online through NCLOR)
• Sample activities and homework
• Handouts for motivational interviewing practice
• Sample applications for credit (available online
  through NCLOR)
• Evaluation tools for demographics and lifestyle
  choice self assessments
• My email melanie.bunn_at_yahoo.com

109

• This workshop has been produced with the generous
  support of
• The Fullerton Foundation, Inc.
• For more information on continuing programs
  that support CNA learning contact
• Duncan Howe, University of South Carolina,
• School of Medicine
• (Duncan.Howe_at_uscmed.sc.edu) or
• Claudia J. Graham, Duke University Medical
  Center, Department of Community and Family
  Medicine, Division of Community Health
  (Claudia.Graham_at_duke.edu)