Motivational Interviewing Assignment
For the purpose of this assignement this student will identify 4 principles of Motivational Interviewing (MI) based on Miller and Rollnick’s (2002a) skilful clinical method of communication, comparing and contrasting these principles with the Digial Recording from my Laboratory work, concluding with the contribution that MI has made to the provision of nursing practice.
What is Motivational Interviewing:
The World Health Organisation (WHO) clearly identified Health Promotion as
“… the process of enabling people to increase control over, and to improve, their health…” (WHO 1986), however, there have been “feelings of frustration” recorded from primary health care workers (HCW) when interacting with patients in relation to making healthy lifestyle changes. This has been attributed in part, due to a lack of motivation in patients and therefore the patient may be adverse to change (Percival, 2013). Miller & Rollnick (2002b) hope that HCW by using a collaboration of MI techniques may bring about positive change within a patient, by promoting their hopes and aspirations for the future, drawing on their tangible strengths and using motivation as the mechanism to achieve this change. Indeed, Miller and Rollnick (2002c) defined MI as: “It is a collaborative, not a prescriptive, approach, in which the counsellor evokes the person’s own intrinsic motivation and resources for change.”
Principles of Motivational Interviewing:
Miller & Rollnick in 2002 identified a number of guiding principles for MI; expressing empathy, develop discrepancy, roll with resistance and support self-efficacy, further reviewed by Rollnick et al. (2008) and expressed using the acronym RULE: Resist the righting reflex, Understanding person’s motivation, Listen with empathy and Empower the person. To achieve success in MI using these principles, there are certain skills that must be utilised in a positive and effective outcome, for instance asking open questions, affirming the strengths of the patient and reflecting back or summing up what you have heard.
Assess and critique of digital recording using identified principles:
Resist the Righting Reflex:
A natural and automatic reaction of the HCP is to make things “right” by fixing a problem, this stems from their training and experience in healthcare. Through the role play I feel that I spent too long trying to redirect the patient back to the topic of smoking, wanted to right the situation and I wouldn’t take verbal and nonverbal cues that the patient did not want to talk about smoking at that given time, it seemed to me that she had a greater desire to vent her feelings about her current marital situation including the recent infidelity, from a biopsychosocial perspective this was central to her recovery, and yet I returned on a number of occasions to the question of smoking albeit in a covert manner.
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The patient was in a state of pre-contemplation (Prochaska and DiClemente 1986), whereby she didn’t want to engage in any confrontational situation, believing that she did not need to change her habits regarding smoking, upon reflection the patient appeared pressured to into accepting change which further exacerbated her lack of desire to change. It appears that there was an increase in persistent resistance from the patient, which was as a direct outcome of me reverting back to the issue of smoking, therefore it is probable to say that in this scenario as a result of my desire to “right” the situation, I in fact made it worse, creating an underlying tension which was not beneficial for the patient’s recovery.
I feel that a better approach would have been to gently broach the subject, with an understanding and acceptance that this was not the right time to discuss smoking cessation as the patient had other ongoing stressors. If by looking at and talking with the patient about her current biopsychosocial and socioecological stressors, I may have developed greater insight into what exactly may motivate this patient, therefore giving me clearer collateral to help develop my objective of discussing smoking cessation.
Exploring and understanding the individual’s motivation:
The patients own motives for change are more often than not prone to initiating change, however, in this scenario there was no indication that the patient was voicing any indicators that they wanted to change their smoking habbit, yes, she had mentioned that she had given up in the past and though I tried to develop that area it was met with resistence. Instead of trying to reason why this person isn’t motivated, I should have looked at what it is exactly that motivates her, irrespective of her current situation. There was scope to develop this as the patient showed great concern for her children, a key discrepancy in her concerns and her current smoking habit, this is a focal point that I should and could have developed further.
In her current situation the patients’ confidence appeared to be extremely low, however I could have measured a true subjective rating in her confidence level by asking her a simple rating question “to rate from 0-10 how ready are you…”. This would have given me a springboard on which to probe for further motivational factors. Again by asking simple open ended questions such as: “what do you want to achieve? or how important is this for you?” it would have given greater insight into what motivates the patient by denoting what their goals are. As such, my focus was to talk about smoking cessation and unfortunately I didn’t pay much attention to signals; identifying what interests and concerns the patient was currently experiencing.
There were small marked areas of ambivalence, which some (Mill & Red 2008) regard as normal in MI and it was apparent at this time that the cons to giving up smoking outweighed the pros thus the patient appears to be somewhat unmotivated.
Listening with empathy
Empathy entails the HCP to listen to and engage with the patient in a non-judgmental manner.
I expressed an understanding of how personal this experience was for the patient asking them to focus on their own issues and recovery, it could have been very easy for me to have been blasé about the circumstances leading up to the admission, accepting what the patient was telling me in a non judgmental way. Giving a summary reflection, I paraphrased what the patient had told be asking for affirmation that I had an understanding of the current situation, which helped me to contextualise and use the patient’s own frame of reference. I listened for ‘change talk”, but couldn’t identify any desire, ability, reasons, need, commitment or taking steps towards instigating change, therefore the patient may not have been ready to engage in MI, however, it was a brief encounter of 5 minutes, giving me good insight into the patient’s current situation. The patient may not have been able to articulate their true convictions because of fear, lack of cognizance or increased anxiety due to her physical ill health and also the far reaching impact of her partner’s infidelity. Upon reflection my opening of “tell me about your problem” was poor and should have been more open and empathetic could have been more, I should have used “tell me about it”
I felt that I displayed some very good attributes to listening empathetically; my body language and posture were open, engaging and receptive. I was non-confrontational or judgemental and verbally exhibited this through an appropriate use of tone and pitch, however, as mentioned earlier, I missed some important cues and felt that I didn’t ‘roll with resistance’, though it must be noted that working in a psychiatric environment there are less time constraints and more opportunities to develop an augmented MI working relationship with a patient.
Empower the patient:
Erickson et al. (2005) deemed that a person can increase their belief in the probability of change based on their ‘past successes’, so by focusing on the patient’s strengths and allowing them to achieve their own goal(s) the HCP can give the responsibility, ownership and control of choices back to the patient. It is within this stage that the HCP has to be a facilitator and motivator to the patient. Again the use of ‘scale questions’ can be very beneficial to the patient allowing them to rate how they perceive their situation allowing them to focus on their skills and strengths.
As with all interventions in nursing, the skillset is with the clinician and MI can only work effectively if used correctly. Throughout the role play there were a number of positive example of where I was empowering the patient, starting with “I am not hear to lecture or preach to you, just to talk to you…” this I felt set expectations with the patient though it could have been more specific to smoking cessation. Focusing on strengths and positives; I asked “what did you do before to give…” showing the patient that they have succeeded in stopping smoking in the past. The patient expressed concerns about intrinsic family issues, though acknowledging that these are important, I advised the patient to focus and ‘concentrate on themselves in the here and now’.
There were a number of pitfalls that I should have avoided such as using technical terms ‘psychosocial/biopsychosocial’ as the patient may not have understood what I meant, I should have kept it short and simple, mirroring the language used by the patient. Another area that should have been avoided was when I asked “when did you start smoking again? I know you don’t want to talk about it but..” as I feel that this reaffirmed a negative with the patient, contrasting strongly with the strengths and positives previously identified.
Patients’ own arguments for change can be more persuasive than any arguments that an HCP may put forward, but it must be noted. Concentrate on the here and now…
It is fundamental that the HCP engages with the client in an open, non-confrontational manner with the HCP not falling into the trap of being the expert trying to assess the patient, apportioning blame or having preconceived ideas/beliefs regarding the patient.
The Contribution that MI has mad to Nursing Practice.
MI by the virtue of its patient centredness, MI affords itself to be used in a wide array of clinical settings through the use of interpersonal relationship (Rollnick and Miller 1995) allowing healthcare providers to be at one with the patient (Sobell & Sobell 1993). There have been, in excess of 200 Randomised clinical trials validating the efficacy of MI in a wider cohort of nursing interventions (REF). It appears from the research that there are more studies needed to validate the true clinical efficacy of MI, however, MI has been used successfully in a multiplicity of settings from from smoking/alcohol cessation, improved efficacy in medication adherence, clients with Cancer (Thomas et al. 2012) HIV, weight management, indeed MI could and should be used all encounters between HCP and patients. The UK’s National Health Servce is rolling out a programme through all sectors about “making every encounter count” which has its basis in MI.
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The WHO actively encourages the use of MI for those working on a quit lines when used in combination with theoretical approaches (WHO, 2014). Talking therapies have been complimented by the symbiotic use of MI in the promotion of health and as such must be embraced across all segments of the health sector, affording self-efficacy in positive outcomes for the patient.
Mill & Red 2008)
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