Motivational Interviewing free essay sample

Reprinted with permission from Health Communications, publisher of Counselor (formerly Professional Counselor), www. counselormagazine. com. All rights reserved. Removing Barriers: Dual Diagnosis Treatment and Motivational Interviewing In the past, traditional treatment methods for drug addiction and alcoholism have been characteristically intense and confrontational. They are designed to break down a client’s denial, defenses, and/or resistance to his or her addictive disorders, as they are perceived by the provider. Admissions criteria to substance abuse treatment programs usually require abstinence from all illicit substances. Potential clients are expected to have some awareness of the problems caused by substance abuse and be motivated to receive treatment. In contrast, traditional treatment methods for mental illness have been supportive, benign and non-threatening. They are designed to maintain the clients already-fragile defenses. Clients entering the mental health system are generally not seeking treatment for their substance abuse problems. Frequently clients within the mental health system who actively abuse drugs and alcohol are not formally identified. We will write a custom essay sample on Motivational Interviewing or any similar topic specifically for you Do Not WasteYour Time HIRE WRITER Only 13.90 / page If they are, they do not admit to such substance use. As some attention began to focus on clients with both substance abuse problems and mental illnesses, it quickly became apparent that new methods and interventions were necessary. Working with dual disorder clients who deny substance abuse, who are unmotivated for substance abuse treatment, and who are unable to tolerate intense confrontation, required a new model, a non-confrontational approach to the engagement and treatment of this special population. I first developed such a treatment model in 1984, with the goal of providing nonjudgmental acceptance of all symptoms and experiences related to both mental illness and substance disorders. A brief history Such treatment interventions and integrated programs which truly adapted to the needs of severely mentally ill chemical abusers had their genesis in 1984 at a New York state outpatient psychiatric facility. In 1985, these integrated treatment programs were implemented across multiple program sites. Concurrently, treatment and program elements were taught through training seminars in New York as well as nationally. In September 1986, the New York State Commission on Quality of Care (CQC) released the findings of 18 months of research. In their report, they described the detachment and downward spiral of dually diagnosed consumers, who were bounced among different systems with no definitive locus of responsibility. As a result, New York’s governor designated the state Office of Mental Health as the lead agency responsible for coordinating collective efforts for this population. The commission visited the dual diagnosis programs developed in 1984, and declared the treatment interventions, the training, and integrated programs to be positive solutions to the dilemma. When a 1987 Time magazine investigation of these programs revealed that at least 50 percent of the 1. 5 million to 2 million Americans with severe mental illness abuse illicit drugs or alcohol as compared to 15 percent of the general population the doubly troubled were brought to the attention of the general public. A gubernatorial task force declared its vision for statewide program development and a training site for program and staff development in the treatment of mentally ill chemical abusers was created to attain that vision. Short-term and on-going training and program development was provided to hundreds of New York’s treatment providers at both state and local mental health and substance abuse agencies. Consumer-led and family-support programs were also developed. The state produced a training video that demonstrated the integrated treatment model, however, the training site closed in 1990 due to budgetary considerations. Programs and groups that grew out of this model continue to be an important nucleus of current services in New York and nationally. These treatment interventions evolved in adaptation to the needs of the dual diagnosis clients. Methods and philosophies clearly differed from traditional substance abuse treatment. Consumers who were actively abusing substances, physically addicted, unstable, and unmotivated, were engaged through a non-confrontational approach to denial and resistance, and acceptance of all symptoms. Consumers participated in treatment groups without pressure to self-disclose, and explored topics from their own erspectives. Subsequent providers either learned from this model, or came upon similar processes through their own experimentation. How it works The phase-by-phase interventions from denial to abstinence begin by assessing the clients readiness to engage in treatment. Readiness levels are accepted as starting points for treatment, rather than points of confrontat ion or criteria for elimination. Mental health and substance abuse programs who integrate these programs, implement screening forms to identify clients who have dual disorders. Identified clients are followed up for engagement and assessment of readiness. Clients are encouraged to participate in dual diagnosis treatment even if they do not accept or agree to the presence of a substance disorder. Clients may participate on the basis of their interest in learning more about mental health and substance disorders, or with the belief that they may be able to lend support to others who are seeking help, among other reasons. The process then proceeds from identification to the engagement phase. The objective in the engagement phase is to develop comfortable and trusting relationships and, if possible, to expose the client to information about the etiology and processes of these illnesses in an empathic and educational manner. The client is given the opportunity to critique the information presented, rather than being told about any particular fact. Interaction effects between symptoms of mental illness and substance disorders are also included in this exploration. Clients at this phase are not required to disclose personal experiences or to admit they use or abuse substances until they are comfortable doing so. The inclusion of educational materials and discussion topics allows for discussion of the issues and impersonal participation. Clients are encouraged to move along a continuum from â€Å"exploration† to â€Å"acknowledgment† of their symptoms. This includes: * attaining a level of trust necessary to discuss their own use of substances and/or symptoms of mental illness; * the exploration and subsequent discovery of any problems or interaction affects that result from substance use and mental health symptoms; * considerations and motivation for addressing these problems; * active engagement in a process f treatment that seeks to eliminate symptoms; * attainment of partial or full remission; * and participation in an individualized maintenance regime for relapse prevention. These programs are implemented as components of existing mental health, and substance abuse programs, and thereby provide integrated treatment. Materials developed for the implementation of this treatme nt process include screening instruments, with separate instruments used for detecting substance abuse among persons who are known to have a mental illness, and detecting mental illness among those persons who are known to have substance abuse/dependence. The pre-group interview provides engagement strategies and a scale to indicate the clients level of readiness or motivation to participate in treatment. The comprehensive assessment reviews past and present mental illness, substance abuse, and interaction effects. Forms for progress reviews and updates include criteria necessary to measure change throughout the phases of movement toward readiness for treatment, active treatment, and relapse prevention. Forms for data collection include programmatic information regarding statistics, client participation, and outcome. See Figure one. Figure 1: Sciacca Treatment Model for Dual Diagnosis* Program Form/Intervention 1. Screening: Mental health, dual disorders, DD CAGE, substance abuse, MISF. 2. Pre-group interview and readiness scale. Engagement. Process and Outcome Identification of potential dual diagnosis clients. a. Engagement into group treatment; b. Assessment of readiness level (1-5). Client requires engagement beyond pre-group interview. Phase 1: Client does not disclose personal situation, participates in discussions or educational materials/topics, develops trust. 3. Continuation of engagement (when applicable). 4. Provide group treatment. 5. Complete monthly data form for each group. . Administer comprehensive assessment (phase two): Phase 2: a. Client discusses own a. Integrate information into treatment plan; b. Make diagnosis. 7. Client progress review updated periodically, includes readiness scale. substance abuse/mental health. Continuation of Phase 2: b. Client identifies adverse effects, and/or interaction between dual disorders Continuation of Phase 2 : c. Client recognizes impact of symptoms upon well being. Phase 3: a. Client becomes motivated for treatment. b. Client actively engages in treatment and symptom management until stability and/or remission is achieved. . Client participates in relapse prevention. 8. Client continues in treatment and/or relapse prevention. *from Journal of Mental Health Administration, Vol. 23,No. 3 Summer 1996, SAGE Publications Program Developmnet Across Systems for Dual Diagnosis: Mental Illness Drug Addiction and Alcoholism, MIDAA by: Sciacca, K. Thompson, C.. pp. 288-297. Motivational interviewing As the dual diagnosis treatment model for substance abuse treatment evolved within the mental health system, motivational interviewing evolved within the field of alcoholism treatment. Some striking similarities can be found in both philosophy and methodology in comparison to dual diagnosis treatment, including the points of departure from traditional substance abuse treatment: Dual disorder treatment and motivational interviewing: * forego traditional treatment-readiness criteria and begin at the clients stage of readiness/motivation and degree of symptomatology. * do not utilize intense, confrontational interventions in response to denial or resistance. * advocate the need for the development of trust as essential to the treatment process. advocate acceptance, empathy and respect for the clients perceptions, beliefs and opinions. They tolerate disagreement and dispel moral and judgmental beliefs. * do not interpret relapse as treatment failure, or employ punitive consequences. * convey and/or provide a hopeful vision, a belief in the possibility of change, and support self-efficacy. The authors of motivational interviewing (Miller and Rollnick, 1991) detailed t he underlying beliefs that form the foundation for intense confrontational traditional substance abuse treatment. They have conducted literature searches and research around the principles of this foundation and have found no supporting evidence for these widely held beliefs. One main example is the belief that motivation is a personality problem. This assumption is that alcoholics, addicts, offenders, etc. , possess extremely potent defense mechanisms that are deeply ingrained in their personality and character. These defenses are considered to be nonresponsive to ordinary means of therapy and thereby justify aggressive confrontational interventions. In view of their findings Miller and Rollnick assert that here is not, and never has been, a scientific basis for the assertion that alcoholics (let alone people suffering from all addictive behaviors) manifest a common consistent personality pattern characterized by excessive ego-defense mechanisms. Within motivational interviewing, confrontation is recognized as a treatment goal not a style. It is part of the change process that includes awaren ess raising. It is likened to Carl Rogers’ client-centered philosophy, which sought to provide a safe atmosphere for the examination of self and change. Like dual diagnosis treatment, confrontation is not used in response to clients denial or resistance. A state of readiness Motivational interviewing strategies correlate to client readiness based upon the stages of change theory (Prochaska and DiClemente, 1984). Stages of change are represented in the form of the wheel of change, which indicates that one can go around the wheel several times. (See Figure 2 for stages, motivational interviewing and dual diagnosis correlates. ) The five principles of motivational interviewing that entail a therapists style as well as strategy also correlate to dual diagnosis treatment interventions. See Figure 3 below. ) Figure 2: Stages of Change and Accompanying Tasks Stages of Change Prochaska and DiClemente Motivation al Interviewi ng Task Miller and Rollnick Dual Diagnois Phase Sciacca Dual Diagnosis Intervention Task Sciacca 1. Precontemplation stage: Person does not consider the possibility for change. Raise doubt; increase clients perception of risks and problems with current behavior. Identification and Engagement: Client identification; engagement process; assessment of readiness level. Phase One: Client is not required to disclose personal situation; participates in discussions of educational topics and materials; develops Engage client to participate in a treatment process that includes exposure and discussion of numerous elements of addictive disorders, recovery, mental illness and interactions effects. Client participation does not require acknowledgment of substance abuse problem. 2. Contemplation stage: Marked by ambivalence; person both considers change and rejects it. Tip the balance, evoke reasons to change, risks of not changing, strengthen selfefficacy. Provide information about discrete disorders and dual disorders; express empathy regarding the real properties of these disorders, including physiology and the process of recovery; dispel moral beliefs and judgements; allow client to participate as critic of information; respect clients knowledge and opinions. trust. 3. Preparation -Determination stage: Person considers various strategies for change. Help client determine best course of action. Phase Two: Client discusses own substance use and mental health; identifies adverse effects and/or interactions between dual disorders; recognizes impact of symptoms upon well being. Phase Three: Client becomes motivated for treatment; actively engages in treatment or symptom management until stability and/or remission is achieved. Phase Three: Client participates in relapse prevention. Assist client to identify and understand adverse effects of symptoms and behavior; provide information and discussion of strategies and treatment approaches that have potential to bring symptoms into remission; administer comprehensive assessment and convey findings to client. 4. Action stage: Person engages in particular actions designed to bring about change. Help client to take steps toward change. Support client’s efforts toward change, including selfefficacy; assist client to make necessary adjustments to utilization of strategies and/or adjunct services or interventions; assist client to recognize or acknowledge positive effects of change as it occurs; assist client to recognize need for continued supports for sustained change. 5. Maintenance stage: Person strives to sustain changes made in action phase. Help client identify and use strategies to prevent relapse; client may exit wheel, into permanent maintenance. Help client renew process of contemplation, determination and action, without becoming stuck or demoralized due to relapse. Assist client to develop network of supports; utilize and adjust to each of these supports; gain a working understanding of clients motivation for change; explore and understand client’s use of deterrents from previous behaviors; explore and avoid potential relapse pitfalls. 6. Relapse stage: Person has minor slips or major relapses; seen as normal part of change process. Relapse: Client has minor slip or major relapse. Assist client to renew motivation and efforts; explore utilization of, or failure to, utilize previous deterrents to relapse; explore and discover possible pitfalls; help client to learn from relapse; relapse is not considered to be a failure of treatment; client does not suffer treatmentmodel-imposed consequences; empathy, support and encouragement are provided until client moves beyond relapse. Removing barriers Dual diagnosis treatment approaches and motivational interviewing interventions represent far-reaching changes for substance abuse treatment and comprehensive services, within both the mental health and substance abuse systems. The removal of the long-standing barriers of traditional substance abuse treatment readiness criteria opens the way for persons with various profiles of singular, dual and multiple disorders, including the homeless, the incarcerated, and others who have been disengaged. These people will be provided an opportunity to develop the trust necessary to participate in an exploration of their situation, and thereby to make informed decisions regarding change These non-confrontational, non-threatening approaches that are necessary for those who have a severe mental illness will also embrace others who might never have the opportunity to participate in substance abuse treatment due to their inability to acknowledge substance abuse as a problem, become motivated, or tolerate intense confrontational interactions. Figure 3: Motivational Interviewing Principles And Dual Diagnosis Correlates Motivational Interviewing Technique 1. Express empathy. This is seen as the corner-stone of the intervention process and relates to all and any experiences conveyed by the client. It is marked by the underlying attitude of acceptance. It includes warmth and reflective listening in an effort to understand the clients feelings and perspectives without judging, criticizing or blaming. It conveys respect. Ambivalence is accepted as a normal part of human experience not as psychopathology. 2. Develop discrepancy. Awareness of consequences is important. A discrepancy between present behavior and important goals will motivate change. The client should present the arguments for change. Dual Diagnosis Correlate Acceptance of all symptoms in all phases is essential. The development of trust is a part of the treatment process. Understanding and pro-viding information about the real properties of each disorder, and dispelling moral beliefs, stigma and judgments is a formative goal. Provide atmosphere that is conducive for client to move toward self disclosure through trust. Assist client to recognize adverse effects and consequences of singular/dual disorders and interaction effects through an integral understanding of information and personal experience. Acknowledge and actualize clients considerations for change through discussion. 3. Avoid Argumentation. Arguments are counter productive. Defending breeds defensiveness. Resistance is a signal to change strategies. Labeling is unnecessary. Clients opinions and beliefs are respected. Therapist and peers may hold different views but they are not expressed in rebuttal to clients beliefs. Defending is unnecessary. A non-confrontational approach to resistance or denial is utilized. Client explores effects or symptoms of various disorders and does not have to accept labels. Topic areas are explored from many different perspectives, with client as critic versus student. The client is a valuable resource in finding solutions to problems. In group treatment all clients participate in finding solutions for themselves and one another. Support, encouragement and the belief in the possibility of change is essential. For clients who have severe mental ealth symptoms that may impair a vision for the future, the therapist must envision the outcome of change and pre-sent such possibilities to the client. The client participates in the course of action for change. 4. Roll with resistance. New perspectives are invited by not imposed. The client is a valuable resource in finding solutions to problems. 5. Support self-efficacy. Belief in the possibility of change is an important motiv ator. The client is responsible for choosing and carrying out personal change. There is hope in the range of alternative approaches available. As the number of mental health and other providers who find the new nonconfrontational approaches to be comfortable and in keeping with their therapeutic style increases, the total number of substance abuse treatment providers will rise correspondingly. This will greatly increase the availability of substance abuse services. Most important, the quality of care will proceed in the direction of the development of trust, respect, empathy, empowerment, and will measure success along a multitude of criteria. The systemic changes will yield both mental health and substance abuse agencies more comprehensive in scope. This will change the course of history that has eliminated dually diagnosed clients and other client profiles who have been deemed unmotivated or not ready for treatment. Agencies may readily include services that employ an exploratory versus expert approach. This will provide many opportunities to provide education within all models of service. For some substance abuse practitioners dual diagnosis treatment and motivational interviewing interventions may represent a dramatic departure from their current practice and echniques. Miller and Rollnick suggest that motivational interviewing techniques be included in ones tool box of interventions and be utilized when traditional approaches fail. It is clear that these new interventions and efforts to accomplish comprehensive care will carry forward into the new millennium. Each of these changes represents models of inclusion and will replace the exclusionary models that have resulted in serious casualties among persons who suffer with sin gular, dual or multiple disorders. Kathleen Sciacca is founding executive director of Sciacca Comprehensive Service Development for Mental Illness, Drug Addiction and Alcoholism (MIDAA) in New York City. She is a nationally and internationally known consultant, program developer, lecturer, and seminar leader for dual diagnosis and a trainer of motivational interviewing. Sciacca is author of the MIDAA Service Manual: A Step by Step Guide to Program Implementation and Integrated Treatment for Dual Disorders, and producer of the education and training video, Integrated Treatment for MIDAA: The Alaska Example. Dual Diagnosis Website: http://pobox. com/~dualdiagnosis Motivational interviewing free essay sample Introduction Motivational interviewing may be defined as â€Å"a collaborative, goal-oriented style of communication with particular attention to the language of change. It is designed to strengthen personal motivation for and commitment to a specific goal by eliciting and exploring the person’s own reasons for change within an atmosphere of acceptance and compassion† (Miller and Rollnick 2012). It is this students aim to demonstrate an understanding of this concept. This will be achieved by critiquing a digital recording of a case scenario that this student previously recorded. Throughout this essay an understanding of the guiding principles used in motivational interviewing will be discussed along with interviewing skills. This student will critique herself on the use of the guiding principles and skills during the digital recording. Skills Motivational Interviewing (MI) involves certain techniques that help bring MI ‘to life’ so to speak. These skills demonstrate the MI principles; they guide the process toward provoking patient change talk and commitment change. We will write a custom essay sample on Motivational interviewing or any similar topic specifically for you Do Not WasteYour Time HIRE WRITER Only 13.90 / page Change talk in a patient is an indication for the nurse the patient is considering the possibility of change. There are different types of change talk which can be described using the acronym DARN. D- Desire (I want to change) A- ability (I can change) R- reason (the importance of change) and N-need (I should change). Another set of vital skills are used to bring about this ‘change talk’. This time the acronym OARS is used. O- Open ended question; these questions are not easily answered by simply saying ‘yes/no’. These questions encourage elaboration. A- Affirmation; these are statements that help recognise patients strengths; this helps the patient feel that change is possible. R- Reflection; this is an important skill in MI; it links in the principle ‘listen with empathy’. This skill is about listening carefully to give reflective responses. This helps the patient feel that s/he is being understood. S- Summarise; this allows the nurse and patient recap on the highlights of the conversation, it can see both sides of the patient’s ambivalence therefore both the patient and nurse can select what information should be included and what information can be minimised. Throughout the digital recording I felt as though I severely lacked these skills however change talk did occur throughout the end with the patient stating â€Å"I know I should change†. Principles The principles of Motivational Interviewing (MI) were developed in 2002; expressing empathy, supporting self-efficacy, developing discrepancy and rolling with resistance (Miller and Rollnick, 2002). Recently new principles were established using the acronym RULE; R- resist the righting reflex, U- understand your clients motivation, L- listen to your client and E- empower your client (Rollnick 2008). Resist the righting reflex: correcting a patient or giving them an alternative rather than providing guidance is often a common flaw among nurses. Resist the righting reflex refers to the inclination of wanting to fix the problem straight away and by doing so decreasing the likelihood of the patient themselves wanting to change (Rosengren, 2009). Throughout the digital recording I can see myself wanting to change the persons smoking habit asking her â€Å"have you ever thought about giving up As it is seriously affecting your health. † Instead I should have asked a more open question such as â€Å"How do you feel about cutting down on cigarettes? † . As a nurse, we have the desire to help our patients change a situation so they become happier, healthier or perhaps lead a more productive life-style. The phrase â€Å"resist the righting reflex† refers to the need to resist the tendency to set our patients on the right track towards the goal we want to achieve with them. As humans we have a natural tendency to avoid persuasion (Rollnick and Miller 2002). We can see this in the digital recording at the start, the minute I offer for her to go and see â€Å"someone†, she immediately backs up by saying â€Å"no, it’s not the right time†. According to Herman et al 2011, when we, as humans, hear reasons why we should change, our minds automatically contemplate reasons why we shouldn’t. In this situation the patient has other â€Å"issues† going on in her life at the present moment rather that quitting smoking. As a nurse I have to accept this. It was poorly portrayed in the digital recording in my opinion. Resistance is the active process of pushing against reason for change (Herman et al 2011). This active process can be influenced by nurses either positively or negatively. Increased resistance may occur by convincing the patient they have a problem, arguing the benefits of change if the patient changes, by telling the patient how to change and by warning the patient of the consequences if they do not change (Moyers et al, 2007). In the digital recording, I can see myself using these negative influences, I warn the patient of serious health consequences caused by smoking, I also say that her â€Å"angina is linked with smoking†. In future I will not take such a harsh approach and let the patient realise him/herself the situation with guidance from myself. I can see I interrupt the patient quite frequently which naturally enough puts strain on the conversation. However, as nurses we can positively influence the patient by using the concept developed by Rollnick and Miller (2002); â€Å"rolling with resistance†. This principle avoids confronting the patient when resistance occurs. Any proclamations or action that may demonstrate resistance remain unchallenged. This in turn helps the patient to define their own problem and therefore can develop a unique solution which leaves little time to resist. In other words, the nurse through guidance and support avoids the ‘righting reflex’, he/she lets the patient express their problem and concern and with guidance, construct a solution while making sure the patient understands the motives for change. Towards the end of the digital recording we can hear ‘change talk’, the patient states â€Å"I know smoking is bad†, I feel I did guide the patient better towards the end eventually getting a deeper insight to her situation and felt a sense of achievement. Understand your patient motivations: In order for the patient to want to change for his/her own benefit, the motivational interviewer must understand the patients motivations. The purpose of MI is that motivation must come from within the patient (Rollinick et al 2008). In other words as nurses we should not motivate our patients; we help them to seek their own unique motivation factor as the patient’s own reasons for change are most likely to trigger change (Miller and Rollinick, 2002). As nurses, we help the patient recognise where they are and where they want to be. It is important for the patient themselves to recognise the discrepancies that already exist and how their behaviour impacts their goal. Miller and Rollinick (2002) describe how a patient may very well want to stop something i. e. their level of alcohol consumption or the amount of cigarettes smoked per day, however they want to and they don’t want to. We can see an example of this in the recording the patient states â€Å"I want to give up but I don’t want to†¦Ã¢â‚¬ ¦this isn’t the right time†. This ambivalence is part of human nature. Patients are naturally ambivalent. It is seen as normal as it is a natural process of change (Tobutt 2011). Rollinick et al, 2008 states that â€Å"When a person seems unmotivated to change or take the sound advice of practitioners, it is often assumed that there is something the matter with the patient and that there is not much one can do about it. These assumptions are usually false. No person is completely unmotivated†. This is seen throughout the digital recording, you can see how ambivalent the patient is. She wants to cut down her smoking habit but it’s not the right time. The patient is seen to lack motivation. However I have used the skill of open questioning to get the patient to express the reason behind this. Through active listening I was able to identify a problem that may be an obstacle in the path to achieve the goal we wanted. At the end the patient identified her own goal, she found motivation from within. Listen with empathy: this principle contains two vital words associated with MI. Listen and empathy. According to Rosengren (2009), listening may be obvious however putting this into practice may prove otherwise. Throughout the digital recording I did look as if I was listening attentively, however I do remember how difficult the skill active listening was. I had to be aware of my body language at all times. Although I have my arms crossed throughout the recording, my body stance was not uninviting in my opinion. Eye contact was also important. I feel I achieved this during the recording without being too empowering. Patients come to us nurses for advice and for our expertise. An environment in which a patient feels comfortable exploring and expressing their feelings must be created. We can create this by being empathetic. In the digital recording it is obvious the patient wanted to talk to myself not some other professional. I did not recognise this at first as I keep saying â€Å"do you want to speak to someone (councillor) about this? † I should have realised this and appreciated the fact that I was the one she wanted to speak to. I repeated this statement too many times; I feel if this was a real life patient/nurse situation, the patient would not open up to me. In future I will be more acutely aware of these situations. To approach a situation with empathy provides an environment for the patient to be heard and understood. Miller and Rollinick (2002) described this type of approach as a â€Å"fundamental and defining characteristic†. Empathy involves seeing the world through the patient’s eyes. If the patient feels understood they open up more and let the nurse or listener in on their deeper thoughts and feelings (McCabe 2004). Rosengren (2009) believes clinicians express this vital principle by using the skill ‘reflective listening’. I feel as if I did not give enough empathy to the patient at the start I did not giving her enough time to speak as I often interrupted. However the patient did open up in the end expressing her deeper feelings to me so perhaps she did feel at ease telling me about her situation. In my opinion I relaxed more as the digital recording went on, this influenced the patient and the conversation flowed more as a result. Conclusion In conclusion this student has learned a lot about motivational interviewing and how important it is to put these principles into nursing practice. MI is imperative to nursing practice, as it involves patient desires, thoughts and feelings as a way to encourage the patients themselves to express their own barriers to change and to explore and resolve ambivalence to behavioural change. This student will take a lot of valuable lessons away with her after completing this assignment. In future this student feels she will have less frustration with those who aren’t planning to change and more patience with those who are contemplating change but are still full of ambivalence. This student has learned how important the skills are in relation to the principles. In order to follow the guiding principles, skills should be followed to achieve the best possible outcome in patient centred care.

Free Essays on Internal And External Landscapes

Internal and External Landscapes Many people would agree that the physical world and our personal disposition are completely different. One’s personal frame of mind varies from each personality, but the physical world does not change. However, perhaps it is possible that one’s outlook can affect their perception of the physical world. Many experiences reflect how one interprets the tangible world. Barry Lopez refers to this as our internal and external landscapes in his short story â€Å"Landscape and Narrative†. His story follows other storytellers and shows the difference between internal and external landscapes and how they are related. It was the day before my birthday when my good friend decided to take me to a concert. I am a big fan of music and I was pretty excited to see this band. It was also going to be my first concert at the Sunshine Theatre, and I immediately liked that environment. The way people react emotionally affects how they visualize the theatre. Some people would have despised the dark, old place and the loud speakers ringing in their ears. I, on the other hand, loved everything from the wicked guitar riffs to the occasional mosh pit. Trusting in those below me, who I had never seen in my life, as I crowd surfed toward the stage without a care in the world, the people seemed to just pass me on while they enjoyed the show as well. It felt like everyone had a similar external landscape because we all understood each others disposition. Knowing that most of the people felt exactly like I did, that their internal landscape was similar, also determined my positive outlook on my externa l landscape. The atmosphere seemed perfect to me because I was enjoying myself, but your internal landscape changes all the time. One transition that clearly stands out in my mind was when I kept getting pushed to the front, right on the stage. At first I though that being so close was going to be even... Free Essays on Internal And External Landscapes Free Essays on Internal And External Landscapes Internal and External Landscapes Many people would agree that the physical world and our personal disposition are completely different. One’s personal frame of mind varies from each personality, but the physical world does not change. However, perhaps it is possible that one’s outlook can affect their perception of the physical world. Many experiences reflect how one interprets the tangible world. Barry Lopez refers to this as our internal and external landscapes in his short story â€Å"Landscape and Narrative†. His story follows other storytellers and shows the difference between internal and external landscapes and how they are related. It was the day before my birthday when my good friend decided to take me to a concert. I am a big fan of music and I was pretty excited to see this band. It was also going to be my first concert at the Sunshine Theatre, and I immediately liked that environment. The way people react emotionally affects how they visualize the theatre. Some people would have despised the dark, old place and the loud speakers ringing in their ears. I, on the other hand, loved everything from the wicked guitar riffs to the occasional mosh pit. Trusting in those below me, who I had never seen in my life, as I crowd surfed toward the stage without a care in the world, the people seemed to just pass me on while they enjoyed the show as well. It felt like everyone had a similar external landscape because we all understood each others disposition. Knowing that most of the people felt exactly like I did, that their internal landscape was similar, also determined my positive outlook on my externa l landscape. The atmosphere seemed perfect to me because I was enjoying myself, but your internal landscape changes all the time. One transition that clearly stands out in my mind was when I kept getting pushed to the front, right on the stage. At first I though that being so close was going to be even...

Dictionary vs. Thesaurus

Dictionary vs. Thesaurus Dictionary vs. Thesaurus Dictionary vs. Thesaurus By Daniel Scocco Afshan Khan asks, â€Å"What is the difference between a dictionary and a thesaurus?† A dictionary is a book containing the individual words of a language (usually organized alphabetically). The purpose of the dictionary is to set forth the orthography, pronunciation and signification of those words. The thesaurus, on the other hand, is a specific dictionary that presents synonyms (words that have similar meaning) for every word listed. This type of dictionary became famous after its integration with word processing software. The purpose of the thesaurus is to help the writer to find more suitable words and avoid the repetition of terms. Online Dictionary and Thesaurus Thankfully you no longer need to visit a library to get access to a good dictionary or thesaurus. There are plenty of websites that offer those resources free of charge. Dictionary.com is one of the oldest and most reliable online dictionaries. On the same website you will also find a link to the sister site Thesaurus.com. Merriam-Webster, one of the most famous dictionaries around the world, also offer an online version. On the same website you will be able to access a thesaurus. Finally, some years ago Google started providing dictionary-like results inside its search engine. Just search for â€Å"define word† to get the meaning to get the meaning of a specific word. Video version of this post: Want to improve your English in five minutes a day? Get a subscription and start receiving our writing tips and exercises daily! Keep learning! Browse the Vocabulary category, check our popular posts, or choose a related post below:20 Computer Terms You Should KnowHow to Play HQ Words: Cheats, Tips and TricksHow Verbs Become Adjectives

Management Change Case Study Example | Topics and Well Written Essays - 3000 words

Management Change - Case Study Example In considering the movement of an organization from one country to another, the impact of the international environment has to be considered primarily as the organizational structure is highly influenced by the international marketing environment. In this discussion we focus on the nature of the organizational structure and the impact of the international environment on the company that is analysed here and would also discuss the cultural and non cultural factors that seem to affect an organization that shifts base from one country to another (Axinn and Matthissens, 2006). We examine the organizational structure, also the international environment and business environment on international marketing strategies. The implementation of the marketing mix is also considered along with the effects of internationalization and movements of a company from one country to another (Axinn and Matthissens, 2006; Balmer, 2006). ... The focus is on understanding the dynamics and relationship between the origin and destination markets. The four elements of marketing mix consist of the marketing tactics and deals with price, place, product and promotion. These four Ps are the basic elements of marketing but recent theories on 7Ps have added people, process and physical evidence in the marketing mix (Balmer 2006, Gronroos 1993). These elements are important as what customers and buyers get will depend on the combination of the suitability of the price, the quality or acceptability of the product in the market, promotional services done to sell the product and the place in which the product is being sold. Thus some major issues in marketing success relate to the place in which a product is launched or promoted and if the environment is suitable for the product then it would be considered as successful in terms of place, as the place is in accordance with the expectations of the company if the product sold and the ma rketing techniques used are commensurate with the needs of the environment or social conditions. As place defines the social environment, it is an important ingredient in the success of any marketing program and is a part of the marketing tool as the place will show the marketing environment to be considered as also issues such as how far the local environment is suitable for launch or marketing of the product (Gronroos, 1993; Balmer, 2006). The place involves the cultural as well as social values, the lifestyle of the people, the preferences of the surrounding locals and residents, and the geographical or environmental factors that can affect the sale of a product

Hitler and Nationlism Essay Example | Topics and Well Written Essays - 250 words

Hitler and Nationlism - Essay Example In addition, the extremist approach to establishing superiority of Germany in Europe facilitated the interest of conquering the entire Europe under the nation. Irrationality in pursuing national goals is another element of nationalism that aided Hitler’s application of the nationalism doctrine to facilitate his objectives. Even though some significant forces disagreed with, they still supported his initiatives based on the notion that Hitler was the best person to spearhead the nation’s interest. Nationalism blinded the forces from their individual philosophies and from the wrongs of Hitler’s goals. Revolutionary aspects of nationalism also facilitated Hitler’s objective by earning him loyalty from forces. Having suffered from conditions of the Treaty of Versailles and depression, Germans were united in rejecting then Reichstag and the revolutionary force gathered support for Hitler’s goals of a more superior Germany (Snyder, 2003; Daniel & Kanarek,

Human equality does not trump that of Nature Essay -- Persuasive, W

My argument that I will make will be that the speaker arrives at the conclusion that he, as well as the human race, is equal to nature. Through the use of a series of examples, I will make my point that both the human race and nature are considered to be equal in array of aspects that are debatable. Through a series of questioning from the child that is reflected back to the child by the speaker, the speaker attempts to take a crack at the meaning of nature’s evidence. E.g. in section 6 the child poses a question which seems to be directed at the speaker, " what is this grass?" Fetching it to me with full hands; How could I answer the child? I do not know what it is any more than he."(99-100) The tone the speaker held was once jubilant and self-praising that ousted the need for criticism of natures grass or it’s flags, and stated " I celebrated myself, and sing myself, â€Å"(1) He does not question and analyze the world as it evolves and blossoms around him until he m oves from his loafing phase. Instead the speaker insists upon observing the motions of nature for example " I loafe and invite my soul, I lean and loafe at my ease observing a spear of summer grass."(4-5) This simple observation is not matched with any sort of debate from the speaker. Instead the speaker leans and loafs and does nothing but enjoy himself in the whims of the summer grass. In the speaker’s effortless state, I would claim that he is similar to a child who coddles in the act of doing nothing. This glorification of the speaker goes out on a whim and outstretches to welcome a deserving partner to join in the loafing as specified in section 5 " Loafe with me on the grass, loose the stop from your throat, not words not music or rhyme I want, not custom or lecture... ... life. The life of a human is then set to change regardless of nature’s input or any other human’s inputs for that matter because every human life holds different meanings and routines. Whitman drives my point home in saying â€Å"And to die is different from what anyone supposed and luckier†. (130) Whitman seems to be implying here that no one can predict the way one person will die and in that sense we are lucky to live a life that is left unobserved on a constant basis and to be at peace is a true gift to be cherished, which goes hand in hand with our death. In the end I would say the speaker has come to recognize nature as having some amount of power, but an equalitarian outlook on life seems to be a viewpoint that Whitman peers through by posing a series of questions that are open-ended and aimed at checking and balancing the power of both humans and nature. Human equality does not trump that of Nature Essay -- Persuasive, W My argument that I will make will be that the speaker arrives at the conclusion that he, as well as the human race, is equal to nature. Through the use of a series of examples, I will make my point that both the human race and nature are considered to be equal in array of aspects that are debatable. Through a series of questioning from the child that is reflected back to the child by the speaker, the speaker attempts to take a crack at the meaning of nature’s evidence. E.g. in section 6 the child poses a question which seems to be directed at the speaker, " what is this grass?" Fetching it to me with full hands; How could I answer the child? I do not know what it is any more than he."(99-100) The tone the speaker held was once jubilant and self-praising that ousted the need for criticism of natures grass or it’s flags, and stated " I celebrated myself, and sing myself, â€Å"(1) He does not question and analyze the world as it evolves and blossoms around him until he m oves from his loafing phase. Instead the speaker insists upon observing the motions of nature for example " I loafe and invite my soul, I lean and loafe at my ease observing a spear of summer grass."(4-5) This simple observation is not matched with any sort of debate from the speaker. Instead the speaker leans and loafs and does nothing but enjoy himself in the whims of the summer grass. In the speaker’s effortless state, I would claim that he is similar to a child who coddles in the act of doing nothing. This glorification of the speaker goes out on a whim and outstretches to welcome a deserving partner to join in the loafing as specified in section 5 " Loafe with me on the grass, loose the stop from your throat, not words not music or rhyme I want, not custom or lecture... ... life. The life of a human is then set to change regardless of nature’s input or any other human’s inputs for that matter because every human life holds different meanings and routines. Whitman drives my point home in saying â€Å"And to die is different from what anyone supposed and luckier†. (130) Whitman seems to be implying here that no one can predict the way one person will die and in that sense we are lucky to live a life that is left unobserved on a constant basis and to be at peace is a true gift to be cherished, which goes hand in hand with our death. In the end I would say the speaker has come to recognize nature as having some amount of power, but an equalitarian outlook on life seems to be a viewpoint that Whitman peers through by posing a series of questions that are open-ended and aimed at checking and balancing the power of both humans and nature.

Employee Mentoring Essay

Jankowicz (2005) mentions, that methodology is the process or approach to undertake a research or study. Prior to follow a methodology, it is essential to understand the research philosophy, which according to Grinnell (1993 cited Kumar, 1999, p. 6) â€Å"research is a structured inquiry that utilizes acceptable scientific methodology to solve problems and creates new knowledge that is generally applicable†. When researching it could be apply to any situation, either for professional or personal purpose. In this case, the main purpose of doing research is to develop an investigation about real situations that may increase or change the knowledge of a particular management problem (Ghauri and Gronhaug, 2002). Therefore, the diverse research methods will be discussed in this chapter, which among other strategies it involves collection and analysis of the research data (Blaxter et al, 2001; Collis and Hussey, 2003). Research Philosophy  The understanding of philosophical positioning of research is useful in the way that helps researchers to clarify alternative designs and methods for a particular investigation and identify which are more likely to work in practice (Ghauri et al, 1995). In this case, research philosophy is about the way the researcher perceives the development of the knowledge and the way the information can be acquire through different processes, besides it provides an ideology to carry out the research (Collis and Hussey, 2003; Saunders et al, 2003; Bryman, 2004). Therefore, there are two main views related to research philosophies: positivism and phenomenological, which is also known as interpretivism approach (Denscombe, 2002; Collis and Hussey, 2003; Saunders et al, 2003; Jankowicz, 2005). Saunders et al. (2003) point out that the phenomenological approach proposes the discovery of subjective meanings in for example humans’ behavior in order to understand and give interpretations to their actions and reactions to particular situations (Collis and Hussey, 2003; Saunders et al. , 2003). Nevertheless, it is important to have in mind that one is not a better philosophy than the other. The philosophy â€Å"depends on the research question that the researcher is seeking to answer† (Saunders et al, 2003, p. 85). From the above mentioned, the research philosophy of this study is based on the develop of skills and knowledge without aiming to generalized and seeking for the truth, but to focus on understanding of human behavior based on the descriptions and experiences of people in specific situations (Collis and Hussey, 2003; Saunders et al. 2003; Jankowicz, 2005). Hence, this research will take an interpretivism philosophy, because the study is related with employee mentoring and attitudes towards job satisfaction and organizational commitment. The role of social learning processes and characteristics of a good mentor may have a great influence on the above mentioned attitudes of employees, which is based on different meanings and interpretations that individuals could have on their own experiences. In addition, Collis and Hussey (2003, p. 7) said â€Å"it is an approach which assumes that the social world is constantly changing, and the researcher and the research itself are part of this change†. Not only the social world is changing, but also the global business environment is and using an interpretivism approach provides flexibility to confront those changes. Whereas the positivistic approach is characterized by seeking law-like results that can be generalized and there is an objective truth that exist in the world and can be revealed through the scientific method, where the focus is on measuring relationships, systematically and statistically, between variables. Research Approach According to Saunders et al (2003), a research is conducted to analyze existing theories, or to establish new theories as a result of recent findings. This will depend on whether the approach is deductive or inductive. A deductive approach is where the researcher develops a theory which will be tested, whereas an inductive approach is where the theory will be developed from the analysis of the data that is going to be collected. The nature of this research is not to find a specific theory but an explanation of an existing situation, for example, in today’s global business environment. Therefore, this research will place the inductive approach which is closely related with the interpretivism philosophy due to its characteristic of not assuming results that are inferred from general conjectures, but developing an explanation from the data collected where general conjectures are induced from specific cases (Jankowikz, 2000; Collis and Hussey, 2003; Saunders et al. , 2003). Research Purpose  An important part of a research and mainly seeing it from the perspective of its objectives, is to identify the purpose of it, which according to some authors can be classified as exploratory, descriptive, explanatory and predictive (Kumar, 1999; Saunders et al. , 2000; Collis and Hussey, 2003). Whereas, the exploratory study is carried out to explore areas, identify variable and look for hypothesis instead of confirming hypothesis, the predictive study forecasts the result of an event and anticipate the outcomes of that event which is under study. On the other hand, an explanatory (analytical) study focuses on studying a situation or a problem in order to discover and measure the relationship between variables, while a descriptive study identifies, describes and provides information of a particular issue (Kumar, 1999; Saunders et al. , 2000; Collis and Hussey, 2003). Therefore, the purpose of this research, taking into account its objectives is exploratory due to the fact that it tries to examine the impact of employee mentoring on their attitudes towards job satisfaction and organizational commitment. The role of social learning processes is also very important in the relationship between mentoring and job attitudes. The qualities of a mentor also play a great role in this relationship. Hence, it would lead to find strategic recommendations for the organization involve in this investigation. Data Collection To answer the research question and achieve the objectives of the research there is the need to collect data, (Saunders et al. , 2000). There are two main data resources, secondary and primary data. Secondary data is the one that already exists from previous investigations and it can be found in books, journals and films (Saunders at al, 2003). Primary data is the one that is recollected from the research and it can be obtained by using methods such as questionnaires, interviews, focus group, and other (Collis and Hussey, 2003). Saunders et al. (2003) points out that literature review helps to develop an understanding and insight into relevant previous research. Collis and Hussey (2003), add to Saunders’s point of view saying that exploring the existing literature will help to have a better overview on previous research that has been conducted and its impact on the studied research problem. In addition, Saunders et al (2003) classify the secondary data into three types: documentary, survey-based and multi-source. For this investigation, it will be useful the documentary secondary data because written documents such as articles taken from the Internet, journals, books among others, could be relevant information to be used.