September - APNA

CLINICAL CARE
1. Express empathy 2. Develop discrepancy 3. Roll with resistance 4. Support Self-Efficacy
Accept where the patient is at Use decisional balance Avoid argument Acceptance
Use reflective listening Confidence and importance ratings Reframe Positive reinforcement and encouragement
Work with ambivalence Direct the intentiontowards change Reflect Acknowldege past successes (even part-success)
Elaboratewith the patient
Involve the patient in problem solving
Table 1. Principles and Strategies of Motivational interviewing.
Confidence
10
9
8
7
6
5
4
3
2
1
0
1 2 3 4 5 6 7 8 9 10
Figure 1. Importance, confidence and readiness to change.
a scale from 1 to 10 How confident
would you say you are that you could
stop smoking on the same scale
from 1 to 10 It also builds on the
patient’s sense of autonomy, keeping
the focus on what they believe and
feel, not what the nurse or GP
believes. If the patient scores low, a
follow-up question could be asked
about what they believe would help
move them further along the scale.
These questions can also open up
the space for a ‘patient centred’ yet
directive dialogue between nurse
and patient, exploring the patient’s
ambivalence and helping build
motivation for change. The aim is
to work collaboratively with the
patient, avoiding direct confrontation.
Miller and Rollnick 9 describe
four principles of MI, each of which
is supported by a range of strategies
(see Table 1).
Expressing empathy involves
using all our previous training in
good basic communication skills.
Attending well to the patient, using
an open posture, employing skilful
and reflective listening and
summarising back what the patient
said will all help build a sense of
empathy and understanding with
the patient. Similar skills are used in
affirming the patient’s efforts and
Importance
building his/her self-efficacy and
confidence about the future.
Developing discrepancy means
building on the dialogue that starts
with the importance and confidence
questions. The aim is to help
patients clarify important goals
for themselves and to explore the
consequences of their current
behaviour, pointing out that there
may be a discrepancy between these
consequences and the goals they
may have. Exploring both sides of
the equation is what is meant by a
‘decisional balance’. Again, talking
about smoking is a good example.
Key open questions can be: What
are all the good things you enjoy
about smoking What are some
of the less good things about your
smoking Helping the patient to
make this an extensive list can
give you a chance to weave in
information about the known harms
and health damaging effects of
smoking. If the patient can’t identify
many negatives, additional questions
could be: What is there about your
smoking that other people might see
as reasons for concern What are
some of the hassles that your
smoking may have caused How
does your smoking fit in with your
diabetes/asthma/hypertension
Generating positive talk from the
patient about the possibility of
change can be useful, with questions
such as: What are the things that
you would like to have in your life
instead of tobacco If you did make a
change to your lifestyle, how would
you like things to turn out Who are
the people in your life that would
support you in quitting
Rolling with resistance means
reframing barriers that the patient
may raise. ‘I couldn’t get through all
the stress at work without smoking!’
might be reframed as ‘It’s good that
you have managed to identify some
of the triggers that keep you
smoking. Let’s think about how we
could help you deal with that stress’.
Motivational interviewing will
not be suitable for all people or all
situations. But it can be a useful
strategy to employ when you have
reached a block with a patient
around a lifestyle behaviour that
seems to be a problem. It can help
you get beyond assumptions you may
be making subconsciously that this
patient is being ‘difficult’ and should
take your advice now and change his/
her lifestyle. It can generate new
ideas for both you and the patient.
The skill is to weave it into the
complex ongoing relationship that
develops between a practice nurse
and a patient over time.
References
1. Commonwealth Department of Health
and Aged Care. Building a 21st Century
Primary Health Care System: Australia’s
First National Primary Health Care
Strategy. Canberra: Commonwealth
Department of Health and Aged
Care; 2010.
2. Commonwealth Department of Health
and Aged Care. Taking Preventative
Action — A Response to Australia:
The Healthiest Country by 2020 —
The Report of the National Preventative
Health Taskforce. Canberra:
Commonwealth Department of Health
and Aged Care; 2010.
3. Britt H, Miller G, Charles J, Henderson J,
Bayram C, Pan Y, et al. General practice
activity in Australia, 2008–09. Canberra:
AIHW; 2009.
4. The Royal Australian College of General
Practitioners National Standing
Committee — Quality Care. Smoking,
Nutrition, Alcohol and Physical activity
(SNAP): A population health guide to
behavioural risk factors in general
practice. Melbourne: RACGP; 2004.
5. Halcomb E, Moujalli S, Griffiths R,
Davidson P. Effectiveness of general
practice nurse interventions in cardiac
risk factor reduction amongst adults:
A systematic review. International
Journal of Evidence-Based Healthcare.
2007;5(3):269–295.
6. Ashenden R, Silagy C, Weller D.
A systematic review of the effectiveness
of promoting lifestyle change in general
practice. Fam Pract. 1997;14(2):160–176.
7. Lai D, Cahill K, Qin Y, Tang J.
Motivational interviewing for smoking
cessation. Cochrane Database of
Systematic Reviews. 2009(1).
8. Rubak S, Sandboek A, Lauritzen T,
Christensen B. Motivational interviewing:
a systematic review and meta-analysis.
Br J Gen Pract. 2005;55(513):305–312.
9. Miller WR, Rollnick S. Motivational
interviewing: preparing people for
change. 2nd ed. New York: Guilford
Press; 2002.
Dr John Furler MBBS, FRACGP, PhD
Senior Research Fellow Primary Care Research Unit
Department of General Practice The University of
Melbourne
September 2010 Primary Times 15