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“Why should I write this paper?” “What is motivating me?” Questions like these are a natural occurrence in our lives, adapted to different sectors. There can be several reasons for one to act, but what drives the action is motivation. Further, motivation to change is even more difficult, overriding what has been engrained and routine. For others, such as people living with mental illness, motivation to change is a complex and difficult process. Mental illness is a challenge within itself. Coupled with other medical comorbidities and oftentimes substance abuse issues, the motivation to change negative health habits seem out of reach. This report will examine what motivates people with mental illness to change. Internal factors elicited by motivational interviewing, external motivators such as vouchers and financial rewards, and natural motivators in the community, are motivators for persons with mental illness and substance abuse problems to change their behaviors.

Motivation can be defined as a reference to a “central mechanism or constellation of mechanisms that lie at the heart of why and how people change addictive and health behaviors,” as defined by Bandura (as cited by DiClemente, Nidecker, & Bellack, 2008). This is independent from the outcome, whether or not a behavior is changed. Different things motivate different individuals, based on their values, culture, and lived experiences. In the mentally ill population, DiClemente, Nidecker, & Bellack state, “individuals with two or more diagnosable psychiatric conditions are often differentially motivated,” highlighting that this population may have unique motivation mechanisms (2008). The challenge in this population is that the mentally ill often have co-existing psychiatric issues, co-existing medical issues, and oftentimes substance use disorders. In fact, it has been cited that half of all individuals with chronic and serious mental illnesses have met the criteria for a substance use disorder, indicating a need for change to achieve better health outcomes (DiClemente, Nidecker, & Bellack, 2008).

Theories about motivation have similar, broad concepts about an individual’s interest and need for change, their goals and intentions, the need to take ownership and commit to change, and the sustenance of changed behavior with “adequate incentives for change” (DiClemente, Nidecker, & Bellack, 2008). Specifically, the trans-theoretical model involves several stages of change. The stages are categorized as pre-action and action-oriented stages. Pre-action includes precontemplation, contemplation, and preparation. Action-oriented stages involve implementing the actual changed behavior and the maintenance of sustaining the change. Successful resolution of the preceding stage lays the groundwork for advancing to the next stage, with cycles of the stages reoccurring (DiClemente, Nidecker, & Bellack, 2008).

As all lived experiences are unique, motivators are unique to the individual. One way to extract what motivates someone is to employ motivational interviewing. Motivational interviewing accepts the patient as a unique individual, making this technique patient-centered. It begins with patient engagement, with the focus being on their concerns. Motivational interviewing is an evidence-based technique that has been successful for providers in eliciting information from clients. Motivational techniques using motivational interviewing has been cited as promising in interventions for improving medication adherence and treatment regimen by studies from Zygmunt, Olfson, Boyer, and Mechani, and Swanson, Pantalon, and Cohen (as cited by DiClemente et al, 2008). Motivational interviewing utilizes “collaborative goal setting that recognizes harm reduction and small steps in reaching larger goals” (DiClemente, Nidecker, & Bellack, 2008). The interaction between the patient and the provider entails discussion about individual values and concerns without confrontation nor pressure and identifying reinforcers that can support the goal to change a behavior or behaviors (DiClemente, Nidecker, & Bellack, 2008). With the skills of the provider and maintaining a judgment-free space and the client’s ability to communicate, motivational interviewing will allow for the identification of motivators. With the identification of motivators, the provider can better tailor a plan to motivate a client to change (that is, if the client wants to change). Motivational interviewing operates under the premise that nothing is forced or pressured onto the client. Resolutions and thoughts are drawn up from the client, with the provider acting as a buffer and guide to better navigate the thought process for a client. It’s as simple as that- find what motivates someone, use it as an incentive for change, and the change will be enacted.

On the contrary, simplicity is not to be taken for easiness. It takes a certain level of cognition and consciousness for someone to identify what motivates them, to communicate it, and to sustain the motivation for change. In the population with mental illness, it is argued that some of these clients do not have the ability and cognition to identify motivators. DiClemente et al pose questions that include if the mentally ill population can “access the intentional process of change and make use of decision making, intentionality, commitment, planning, and experiential and behavioral processes of change when they make changes in their substance-abusing or adherence behaviors” (2008). Further, DiClemente et al question if mental illness with cognitive impairments will interfere with decision-making and if it will hamper self-evaluations (2008). Additionally, the Center for Substance Abuse and Treatment state the “more severe the mental illness and the substance abuse problems are, the more dysfunctional thought processes, impaired decision-making skills, and the lack of insight diminish the ability to recognize the need for treatment as well as the individuals’ ability to seek and participate in it,” supporting that motivational interviewing will be most effective in the cognitively-capable (as cited by DiClemente, Nidecker, & Bellack, 2008). Other professionals suggest that people with severe mental illness and coexisting disorders “may be more driven by external considerations or reinforcers, seems less intentional, and appears more chaotic than the process among individuals without these problems” (DiClemente, Nidecker, & Bellack, 2008). DiClemente et al state:

“Substance-abusing individuals with mental illness … have attitudes, opinions, beliefs, and intentions that are integral, but often detrimental, to making and adhering to behavior changes. They can have problems with commitment and planning as well as with implementation and revision of those plans. In addition, they can have significant problems sustaining behavior changes over long time periods… They may benefit from external reinforcers to enhance internal processing, the use of less cognitively complex assessment and treatment approaches, and/or stabilizing medications and skills development to help them access the process of change” (2008).

This suggests that there are other motivators that need to be considered with the mentally ill population.

By the same token, there has been much success in external incentive programs for motivation in substance abusing individuals with mental illness. Voucher incentive programs are used as external contingent reinforcers, with specific awards that clients value. Budney and Higgins have tested voucher incentive programs, with much success (as cited by Substance Abuse and Mental Health Services Administration, 1999). Voucher incentives operate under the rationale that an enticing external motivator can be an immediate and powerful reinforcer to compete with drug reinforce. Vouchers will satisfy the need for immediate gratification. As per the Substance Abuse and Mental Health Services Administration, it has been demonstrated that “money or an equivalent alternative is nearly always appealing” (1999). Vouchers are earned for abstinence, with point values, sometimes indicating a cash value. Points are awarded each time the client submits drug- free urine, for example. When vouchers are accumulated, clients trade in their points for goods and services. Options include paying bills with their voucher or spend their money on shoes, clothing, groceries, etc. (Substance Abuse and Mental Health Services Administration, 1999). By allowing individuals to use points and rewards as they want in exchange for changed behavior, they are motivated to move toward a positive direction.

In addition, a motivator to change can be effected by using a Community Reinforcement Approach (CRA). Community Reinforcement Approach involves fusing natural reinforcers to abstinence. The difference from external reinforcers such as vouchers is hat natural reinforcers can be praise, occurring in a normal, every-day environment that the client is in. The ideal situation that the Substance Abuse and Mental Health Services Administration discusses is in employment. There would be an agreement between employer and client in which the client would be allowed to work and earn money when they are drug and alcohol free. The rationale is that the benefits of work and money to be earned become associated with abstinence. Another component is Job Club, which offers skills training and strategies for getting a job (interviewing, dress, applications). The Substance Abuse and Mental Health Services Administration state “employment serves as an immediate reinforcer by meeting the practical need for money, but other aspects of employment take time to become reinforcing” (1999).

In conclusion, motivators to change in people with mental illness are not cut and dry. Motivational interviewing is an excellent tool in eliciting the client’s values and personal motivators, or internal factors, if cognition is intact. External motivators and incentives such as vouchers and financial rewards are also effective in motivating change. Additionally, Community Reinforcement Approaches (highlighting employment) also serve as motivators for change by merging natural and external motivators. The need for behavior change in persons with mental illness and substance abuse is a health problem that needs to be addressed. Traditional treatments may not work in this population due to the existence of other conditions. By using a patient-centered approach, outcomes are likely to be favorable in starting and maintaining a positive change.

References

DiClemente, C., Nidecker, M., & Bellack, A. (2008). Motivation and the stages of change among individuals with severe mental illness and substance abuse disorders. Journal of Substance Abuse Treatment, 34 (1). Retrieved from http://www.sciencedirect.com.citytech.ezproxy.cuny.edu:2048/science/article/pii/S0740547207000980

Substance Abuse and Mental Health Services Administration. (1999). Enhancing Motivation For Change in Substance Abuse Treatment. Center for Substance Abuse Treatment. Retrieved from https://store.samhsa.gov/shin/content/SMA13-4212/SMA13-4212.pdf

Introduction:

At 107-109 Avenue D, part of the Community Access organization, I was given a rare opportunity to be immersed in a learning experience. Formally, I was able to learn about the role of the community health nurse, the nursing profession itself, the Community Access organization, how clients cope with their unique conditions, and how to work with this specific population. In the midst of that experience, I was fortunate enough to be guided well to gain “unobservable” knowledge, or, internal skills such as self-reflection, self-awareness, and emotional intelligence. At 107-109 Avenue D, I was encouraged to fulfill several objectives that shaped me in my personal and professional growth.

Objective 1: Demonstrates individual professionalism through personal behaviors and appearance.

Firstly, objective one regards individual professionalism through personal behaviors and appearance. Individual professionalism was defined as assuming responsibility for my own learning, preparing from clinical learning, actively participating in conferences, punctual attendance, and professional dress. When guidance was needed, I was sure to reach out to the Professor who supported me through my whole experience. Maintaining client confidentiality and not discussing cases outside of the setting or with people not involved in care also demonstrated professionalism.

Objective 2: Employ analytical reasoning and critical thinking skills when providing care to individuals and families in the community setting.

Secondly, the next objective involves reasoning. With the professor’s guidance with techniques such as motivational interviewing and encouraging us to think, I was able to use my reasoning skills. I interviewed clients and collaborated with the director of the facility to provide necessary care. I looked holistically at clients to assess the impact of developmental, emotional, cultural, and spiritual influences of the client. One client in particular, P., disclosed that he was very into spirituality and we explored how it influences his health. Another client, G., gave us deep insight into her emotional life which helped us guide conversations. Aside from the spiritual aspect, physical assessments were made regarding hygiene, general appearance, and a general survey. We set priorities and goals with the residents to work together safely. As the process went on, we made necessary modifications (if any) to the course of care. Also, by reasoning, safe and unsafe situations were identified and dealt with accordingly. Our main concern was safety for staff, the residents, and ourselves and we were not faced with any compromising situations.

Objective 3: Effectively communicate with the diverse groups and disciplines using a variety of strategies regarding the health needs of the individuals and families in the community setting.

In addition, objective three regards communication in the community setting. Therapeutic communication was utilized and appropriate channels of communication were followed. Given the diverse population, I had to be conscious of my thoughts and the content of my speech. I approached everyone with respect and care and was successful in breaking any potential communication barriers regarding group diversity. There was clear communication with the instructor and feedback was always provided to keep us on track. We worked closely with the director to share any significant findings we had. We used a Community Access Weekly Report log to track and document findings.

Objective 4: Establish environment conducive to learning and use a plan for learners based on evidence-based practice.

By the same token, objective four involves learning as the resident. We held group discussions and meetings as well as one-on one sessions to teach residents about health and health-related practices. We held a tobacco discussion group, nutrition hour, tips on healthy eating on a budget, and other things. We established an environment conducive to learning with the help of the staff that encouraged residents to attend our meetings, minimizing background noise, and holding residents’ attention. Individually, we developed teaching plans based on the goals of the resident. For example, one resident wanted to control their weight and we taught them about diet, nutrition, and exercise. Learning was also evaluated continuously and we had residents re-explain what we explained to them as a form of return-demonstration.

Objective 5: Utilize informational technology when managing individual and families in the community.

Also, there was some form of utilizing informational technology when managing individuals and families in the community, as objective five states. Though we did not utilize informatics heavily, we used Access computers and the web-based database to access and read information regarding clients and care. The Internet and electronic sources contain sensitive information that we knew to keep confidential at all times. We were sure to close out of browsers, make sure no one could read over our shoulders, and log off when finished accessing information.

Objective 6: Demonstrate a commitment to professional development.

Furthermore, objective six deals with professional development. We were encouraged to research and keep current with the issues that surround the community and it’s various populations. Appropriate literature was utilized so that we could make informed decisions with the most up-to-date research and articles. We were encouraged to engage in self-evaluations, which gave us a moment to reflect on our development. In doing this, we were able to identify strengths, weaknesses, and areas of improvement. Also, on this facet of community nursing, we were able to see the professional challenges of the field.

Objective 7: Incorporate professional nursing standards and accountability into practice.

In addition, the seventh objective regards the incorporation of professional nursing standards and accountability into practice. We used the American Nurses Association Standards in clinical practice to guide our interactions. The standards and ethical components of the ANA Standards ensured we were acting professionally and caring efficiently. The agency also had standards of practice regarding conduct, protocol, professionalism, etc., that we were informed about and held accountable for. Also, Community Access held us accountable for their mission and how we can contribute to its pursuit. The mission of Community Access is as follows:

“Community Access expands opportunities for people living with mental health concerns to recover from trauma and discrimination through affordable housing, training, advocacy and healing-focused services. We are built upon the simple truth that people are experts in their own lives.”

Objective 8: Collaborate with clients, significant support persons and members of the health care team.

Moreover, objective eight reflects one of the mist important objectives, which highlights collaboration. At this site, the resident was our main focus. By collaborating with the health care team, we provide a continuation of care that is consistent and effective. We conducted individual interviews to address concerns and set goals. Client needs and therapeutic interventions were explored. In the case of G., we asked her to speak about her concerns in an interview. We then helped her prioritize and come up with realistic plans and goals to address as many of her concerns. For example, the interview revealed that she had some psychosocial needs that needed to be met and that she was feeling that her family ties were not strong. We let her speak candidly and at the end, helped guide her to her own way of addressing her concern. This collaboration and “guided autonomy” allowed her to feel empowered and in control of her situation. We also guided clients on how to make appropriate lifestyle and treatment choices. We coached on nutrition, sleep, habits, substance abuse, medication compliance, health-care provider visit compliance, and more. Furthermore, we assisted clients when we were able to make connections to other community agencies. Though we did not have the initiating-hand in connecting clients to agencies, we encouraged them to seek out other agencies and organizations for assistance. One example of this is finding the number for the Mobile Crisis Unit to help G. with her brother.

Objective 9: Recognize the impact of economic, political, social, and demographic forces that affect the delivery of health care services.

Lastly, objective nine calls for students tor ecognize the impact of economic, political, social and demographic forces. We were able to have first-hand experience in recognizing gaps in the health care system. We worked with a marginalized group that needs assistance that does not receive it. Though premature, I am able to brainstorm a few ideas to fix these problems. One suggestion I have is to educate the public about the health needs of the mentally ill population. With understanding, more people are likely to assist. Fear of the unknown can be alleviated with education and can be a vital first step in a solution. For me, acting as a change agent is one of my personal goals. Now that I have this experience under my belt, I am better able to speak about the issues surrounding this population and can be proactive in making a difference.

Below is a link to the original word document:

community SLP self relfection Danny

The link below  contains a community assessment for the Lower East Side:

LES community nursing part 2 .