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40 JULY 2016 | EMSWORLD.com ferently than we have in our traditional EMS roles. To put these guidelines into practice, however, requires that we learn new com- munication skills. Core Skills Not only does MI involve a different way of thinking about how to help patients, it requires us to practice conversational tech- niques that are vastly different from those we've used in our traditional roles. Not unlike learning to perform a clinical intervention, CPs must learn and repeatedly practice the techniques described below to become more effective at helping their patients. The fol- lowing four conversational skills are the foundation for MI interventions. Ask open questions—The time-sensitive nature of traditional EMS work means we have to sift through lots of information in a very short time frame. We don't have time to listen to the patient explain all the major events in their life they believe led up to the call to 9-1-1; we just want to know what prompted them to call today. When the patient starts going off on a tangent, we redi- rect them using closed questions to which there is little opportunity for elaboration. In community paramedicine we benefit from hearing the rest of the story. Under- standing adverse childhood experiences, a history of physical or emotional traumas and family support systems (or lack there- of) is critical for CPs. These stories help us understand not only why a patient is in their current predicament but what resources may be available to help them. This infor- mation is more likely to be obtained through an open question such as "Tell me about yourself," rather than a closed question such as "Were you ever abused as a child?" Provide affirmations—An affirmation is an expression of a sincere appreciation for some trait or behavior of the client. Shar- ing these observations with the patient can be a powerful tool in building a rapport and confidence in their ability to change behaviors. Miller describes an affirmation as finding what is right with the patient rather than constantly focusing on what's wrong. However, finding these positive attributes can sometimes be challenging. We may not agree with the patient's lifestyle choices, values or behaviors. At times providing an affirmation to the patient means we have to reframe our view of the patient's situation. Given the multiple challenges (self-imposed or otherwise) many patients face, it may be helpful to appreciate that your patient has not given up. In most cases even the most troubled patient can be considered a survivor. Use reflection, not questions—If there is one skill that is critical to master to con- duct MI successfully, it would be the use of reflections. Rather than interrogating the patient with a series of questions to obtain the information we need, MI relies on the skillful use of reflective statements to gath- er the information. Ref lective statements essentially repeat what the patient said as a way of allowing the patient to elaborate. The statements reassure the patient you're listening while allowing you to confirm you understand what the patient is trying to say. Reflections come in two general categories, simple and complex. A simple ref lection simply repeats verbatim or rephrases what the patient just said. Complex reflections are attempts to check the meanings or emo- tions behind the words. Table 1 provides examples of how a sin- gle statement can be reflected back to the patient as an opportunity to explore what the patient really meant. While it seems counterintuitive at first, using ref lective statements can often elicit better informa- tion faster than direct questioning. More important, reflections allow the patient to tell their story without feelings of judgment or interrogation. Use summary statements—The final skill for practicing MI is the use of summary statements. CP visits tend to be longer than traditional EMS patient encounters, and it can be useful for the patient and the CP to occasionally review what has been discussed. For example, you might start a summary statement with, "Mr. Smith, you've mentioned several concerns about your medications, and I want to be sure I'm capturing all the important ones." Then list the individual concerns the patient has mentioned and conclude with, "Tell me what other concerns you might have." Summary statements can be helpful to ensure the CP is capturing all the important information that has been shared. Summa- ries can also be helpful in redirecting the patient when they go off on an unproductive tangent to areas that are more relevant to the current discussion. Getting Engaged Mastering the conversational skills listed above will help the CP be better prepared to help patients help themselves. However, an all too common frustration is those patients who refuse to follow through. These patients may allow the CP to visit but refuse to take any actions between visits to accomplish what they have agreed to do. The result is that the patient fails to make any progress and the CP becomes frustrated with the patient for their apparent unwillingness to help them- selves. Using MI techniques may help correct or even avoid these types of impasses. Miller describes successful MI interven- tions as a four-step process that includes engaging the patient in the partnership; focusing their time on the steps necessary to make progress; evoking ideas from the patient on how to change their behaviors; and planning to implement the changes once a direction has been determined. However, if the patient disengages from the CP or program, the rest of the steps in the process will not be successful. TABLE 1: EXAMPLES OF THE TYPES AND INTENT OF USING REFLECTIVE STATEMENTS The patient says… "I don't like taking that medication!" Types of reflection Simple refection—repeat: "You don't like taking that medication." Simple refection—rephrase: "You don't enjoy taking that particular drug." Complex refection—explore the statement's meaning: "You don't like the side efects that medication causes." Complex refection—explore the meaning and emotions behind the statement: "It's frustrating to deal with the side efects of your prescriptions."