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Guided learning

Motivational interviewing 2: how to apply this approach in general nursing practice

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Health promotion is a vital part of both preventing and managing long term conditions. Nurses can use the technique to promote behaviour change.

Author

Gill Scott, PGCE (Adult), BSc, Dip Therapeutic Nursing (Palliative Care), RNT, RGN, is personal health coach, Humana Europe, and education facilitator, Doncaster Primary Care Trust.

Abstract

Scott G (2010) Motivational interviewing 2: how to apply this approach in general nursing practice. Nursing Times; 106: 35, early online publication.

Nurses could play a major role in improving health outcomes by incorporating motivational interviewing skills in a variety of care settings, potentially addressing some of the productivity challenges faced by the NHS.

This second in a two part unit on motivational interviewing shows how nurses can apply these therapeutic techniques in daily practice. Outcomes after using motivational interviewing are explored in the context of growing emphasis on prevention and health promotion. Part 1 explored the key principles of the approach.

Keywords Motivational interviewing, Behaviour change, Long term conditions

  • This article has been double-blind peer reviewed

Learning objectives

  • Understand the potential of motivational interviewing in the context of health promotion interventions and managing long term conditions.
  • Be able to assess and identify client readiness for goal specific strategies in promoting health behaviour change.

Introduction

The potential of motivational interviewing (MINT) to help people change harmful behaviour is starting to be recognised in a diverse range of clinical settings and patient groups. It is now having an impact on patients’ management of the most serious diseases caused by lifestyle factors in the West (Resnicow et al, 2002).

Work already underway in the US and more recently in the UK, in the form of Humana Europe’s Choosing Health programme, has tested the use of nurses in personal coaching roles. Consequently, nurses’ use of motivational interviewing is likely to increase as trusts increasingly look for return on their investment and quality improvements in the face of service reconfigurations in the current financial climate (Department of Health, 2008a).

Background

Incorporating motivational interviewing in frontline settings can contribute significantly to healthcare reform and frontline clinicians can use these skills effectively in everyday practice (Anstiss, 2009). New corporate quality and efficiency initiatives such as Quality, Innovation, Productivity and Prevention (QIPP) may be served by strategic and influential innovations. For example, trust wide investment in the method could improve efficiency, effectiveness and public health ownership.

Attempts have been made to identify the costs of a dedicated service, although few studies analyse the data in terms of cost benefits. Greaves et al (2008) showed that a maximum of 11 sessions of motivational interviewing over six months, for an average of 34 minutes per session, cost an estimated £263 per client. In terms of achieving the desired outcome of 5% weight loss and 150 minutes’ activity a week, results were less sustainable than with traditional approaches. However, at around seven times cheaper than intensive programmes, this still suggests scope for effective results at much reduced costs.

Numerous papers (Mason, 2009; Knight et al, 2006; Rubak et al, 2005) detail the uses of motivational interviewing in diverse healthcare contexts, although the quality of research varies as some studies are small scale and short term (Wahab et al, 2008). However, there is enough rigorous empirical evidence to suggest that its principles are effective in both research trial and real clinical situations.

Motivational interviewing and long term conditions

There are 15.4 million people living with a long term condition in England. Numbers are expected to rise due to the ageing population and unhealthy lifestyle choices (DH, 2010).

However, managing long term conditions often involves tackling lifestyle issues that the medical system is not well prepared to address. The success of Humana Europe’s Choosing Health programme shows that different approaches are needed to help people take action to regain better control of their health. This successful wellness programme used the best available knowledge about how to engage people in their own health, testing it with a group of obese people in Stoke with outstanding results. For example, one client commented: “I’ve gone from 16.5 to 14 stone, suit size 44 to 36 in three months. Cholesterol went from 6.4 in January to 3.9 now, only with changes in diet/activity” (male client, early 40s) (from an unpublished report).

Using motivational interviewing in nursing

Nurses have a clear opportunity to integrate this therapy into everyday clinical care. Looking at the health needs for which motivational interviewing has been used reveals a vast range of contexts and conditions, including those listed in Box 1.

Roles are also emerging that specifically require the training and expertise of motivational interviewing coaches, who may be face to face or telephone interviewers. Telephone caseloads may be managed through call centre or home working arrangements, contracted to NHS or private employers.

Already some primary care trusts and local authorities have piloted and contracted with health coach service providers. The Choosing Health programme offered health benefits to patients with life limiting illness, while Walk This Way, offered as a partnership between Stoke Primary Care Trust, Stoke Council and Humana Europe, promotes staff wellness initiatives and optional coaching incorporating pedometer step activity uploads to a personalised website account.

Motivational interviewing may be a valuable intervention long before people ever see themselves as a patient or in need of a healthcare professional’s clinical intervention. Often chronic ill health symptoms emerge in mid life and much systemic damage has been done due to ignorance, ambivalence or socioeconomic factors. MINT attempts to reveal health as something we “do” rather than something we “have”.

Specific uses for motivational interviewing

Face to face techniques are useful in a variety of clinical settings such as GP practices or community pharmacies for medicine or treatment concordance. For example, practice nurses may benefit from using motivational interviewing in enabling patients to decide whether or not to accept the offer of a referral for psychological therapy for a mental health condition. The method has been used extensively in supporting diabetes management, which always rests almost exclusively on good self care (Leak et al, 2008). Smith et al (1997) found it resulted in better glucose control post treatment than those in a control group, while de Blok et al (2006) found motivational interviewing recipients with COPD had a 69% increase in pedometer steps compared with a 19% increase on baseline activity in the control group.

District nurses using motivational interviewing could support patients who are ambivalent about engaging in cardiac rehabilitation after myocardial infarction. Home visits to older people could see nurses effectively unearthing mental barriers to client confidence that were having a negative impact on efforts to promote healing of chronic leg ulcers (Morris and White, 2007).

Similarly hospice nurses could use motivational interviewing to elicit patient ambivalence about accepting appropriate levels of pain relief. Fahey et al (2008) suggested a nurse coaching framework for exploring barriers to adequate cancer pain management.

Recent authors of a small study on patients with heart failure using motivational interviewing for self care improvement claimed that this “approach is consistent with nursing’s philosophy of care and builds upon our long-standing traditions” (Riegel et al, 2006). 

Motivational interviewing aims to elicit a client centred goal choice. These skills can be used to address a wide range of health behaviour choices such as smoking cessation, end of life decisions, vaccination related dilemmas, diabetes education and in supporting lifestyle and self management skills using personalised care plans (DH, 2010). They could enable a more proactive approach to health and efficiency savings as a result of clients’ better understanding of causal behaviour choices. This built-in vested interest for clients and commissioners underpins successful change in an era of increasing value placed on the patient/service user voice (DH, 2008b).

Box 1. Uses for motivational interviewing

  • Smoking cessation
  • Promoting condom use
  • Weight loss
  • Pedometer use
  • Exercise uptake
  • Preoperative cardiac surgery preparation
  • Medication concordance
  • Chronic pain management
  • Stroke rehabilitation
  • Fibromylagia
  • Victims of domestic violence
  • Chronic leg ulcers
  • Diabetes management
  • Mental health problems including depression, anxiety, obsessive compulsive or eating disorders and dual diagnosis

Source: Anstiss (2009); Knight et al (2006)

Conclusion

Anstiss (2009) argued that motivational interviewing can offer a groundbreaking vehicle for health reform if deliberately and strategically implemented. It has been argued that the skills are applicable from novice to expert level in a wide range of settings.

Effective use of MINT is timely and possible in general nursing practice. Nurses can apply its principles to promote client engagement and wellbeing.

For more information contact Gill Scott at gill.scott@humana.co.uk

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