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A Motivational Interviewing Education Intervention for Home Healthcare Nurses The ability of registered nurses to communicate well with their patients is foundational to patient-centered care, the management of chronic illness, and general healthcare. It is also vital to the nurse–patient relationship. Nurses, however, tend to identify with their patients’ physical needs and rely heavily on the technical skills with which they feel more comfortable. This lack of ability to communicate well with their patients can result in poor nurse–patient understanding, can lead to poor patient outcomes, and a lack of patient engagement and involvement in their care. Motivational interviewing (MI), a patient-centered manner of communication, is a means to direct the nurse–patient interaction in a way that is patient centered. Brief education of MI has shown to be effective in increasing the self-efficacy of nurses in their ability to communicate well with their patients. In 2 geographically diverse Pennsylvania home care settings, MI education was provided to 20 nurses. The educational intervention was designed to increase the self-efficacy of nurses regarding their ability to affect the negative behaviors of chronically ill patients. A pretest and posttest was administered to the nurse participants to determine the effectiveness of the educational intervention. This evidence-based education increased the nurses’ overall communication self-efficacy by 25%.
February 2015
Joni J. Pyle, DNP, RN
N
urses are tasked to communicate with and educate patients regarding their medical conditions, their treatments, and the behavior changes that can lead to health and well-being. This requires nurses to gain an appreciation of an individual’s physical, emotional, spiritual, and social needs. Interactions of this nature require nurses to have a sound ability to communicate well with those for whom care is provided. Good communication skills practiced by nurses can positively affect patient satisfaction, safety, and patient adherence to their plan of care (Institute for Healthcare Communication, 2011). Motivational interviewing (MI), a patient-centered manner
Home Healthcare Now
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
79
Motivational interviewing, a patientcentered manner of communication, has been suggested as a means to direct the nurse–patient interaction in such a way that communication becomes patient centered.
of communication, has been suggested as a means to direct the nurse–patient interaction in a way that communication becomes patientcentered. It has been found that creating a patient-centered environment enhances the overall patient experience, and patient outcomes (Borrelli et al., 2007). MI encourages self-care and promotes behavior changes by enhancing patient-centered care (Dart, 2011). Patientcentered care requires nurses to engage patients in involvement of their own care. Nurses need communication skills that encourage this patient-centeredness as healthcare shifts to the management of long-term chronic illness and the encouragement of healthier lifestyles, each of which requires active participation by the patient. In fact, the Home Health Nursing Scope and Standards of Practice (American Nurses Association, 2014) charges that the home healthcare registered nurse “develops communication skills that promote behavior change in patients, such as the use of motivational interviewing, counseling, and health coaching communication techniques” (p. 67). MI is a technique that can be learned; however, it is also considered a “spirit” that at its core elicits a patient’s motivation for positive change (Miller et al., 2008). The authors add that it is a way of guiding patients instead of directing; patient autonomy is highly respected. Although this practice is not counter to what nurses currently do, it is a shift in control from that of the nurse to that of the patient. A review of the literature found MI to be effective in helping nurses to more successfully talk with patients (Dart, 2011; Miller & Rollnick, 2013; Rollnick & Miller, 1995). A survey of MItrained nurses found that 91% of nurses with MI knowledge found MI to be easy to use, as well as in alignment with nursing’s theoretical foundation (Söderlund, 2010). Goldstein et al. (1998)
80
Volume 33
|
Number 2
asserted that nurses often initially have difficulty employing MI because they have been trained to offer advice as part of their nursing education. Nurses are, nevertheless, successful with learning and implementing MI. Norgaard et al. (2012) conducted an investigation of 181 healthcare professionals of varying disciplines finding that providing communication skills education increased the self-efficacy of healthcare professionals, as it is associated with patient-centered communication. The literature supports the use of MI in healthcare and its use by the nursing discipline as a means to create a patient-centered delivery of care.
Purpose of the Project In a regional medical center in Pennsylvania, nursing administration found that nursing communication was lacking. It was identified that nurses receive little education directly related to communication with chronically ill patients. Additionally, it was recognized that no communication support was provided to this group of nurses. The institution was anxious to engage in the provision of an educational intervention of MI for its home care nursing staff, as the organization realized the overall benefits of good nurse–patient communication. The question guiding this evidence-based education project was: does providing brief MI education increase nurses’ communication self-efficacy and positively affect their ability to motivate positive change among their chronically ill patients?” It was anticipated that the MI education would increase the self-efficacy of nurses regarding communication with their patients; hence, more significant patient-centered care would take place. This practice would then encourage patients’ increased engagement, greater involvement in their care, and ultimately better healthcare outcomes.
Method The organization’s institutional review board approved this project. The author developed the MI Appraisal Inventory, consisting of a 19-question Likert scale questionnaire, to measure nurses’ understanding and self-efficacy related to the use of MI. Three advanced practice nurses with knowledge of nurse communication and MI reviewed the tool for face validity. The inventory was delivered as a pretest and
www.homehealthcarenow.org
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
a posttest to ascertain if the education intervention resulted in an increase in nurse selfefficacy regarding MI. Setting
The education intervention took place at two geographically diverse locations of the home care agency of a regional medical center in central Pennsylvania. One site was urban and suburban, and the other rural. Ten nurses at each site agreed to participate. All 20 participants were white. In the urban/suburban group, there were nine females and one male, whereas all nurses in the rural group were female. All of the participants had at least 1 year of experience as a registered nurse, but their experience in home care varied. Education of the nurses participating in the project also differed from associate in nursing to master’s in nursing, although the majority of nurses held a nursing associate degree. Intervention
During a normally scheduled team meeting, a 2-hour education session regarding MI use with chronically ill patients was undertaken. Nurses were asked to complete the MI Appraisal Inventory before the education was initiated. The author created a booklet, the Motivational Interviewing Guide, complete with MI information and tools to enhance its use. A copy was given to each nurse to us,e and copies of Motivational Interviewing in Nursing Practice: Empowering the Patient (Dart, 2011) were given to the nurse managers for use as a reference. A presentation including MI background, information regarding the spirit of MI, the principles on which MI is based, the process of MI, and the skills and techniques of MI was conducted with 10 nurses at the urban/suburban location. Tools that nurses might use with their patients during MI use, contained in the Motivational Interviewing Guide, were highlighted and their use explained. An opportunity for questions was presented, and then the group engaged in active role-play providing an opportunity for practice. Finally, nurses were introduced to a form that provided them with the ability to track their daily use of MI principles. The education was repeated, in the same manner, with 10 nurses at the rural location. During the 8 weeks immediately after the education intervention, the project manager
February 2015
contacted each of the nurses and arranged an opportunity to ride-along with the nurse to observe the nurse’s interaction with their patients and their use of MI with those patients. After each nurse–patient interaction, an opportunity for one-on-one questions and debriefing was provided. Feedback provided to the nurse was private, individualized, and aimed at increasing the self-efficacy of use of MI in their daily practice. Following 8 weeks of MI use, the nurses were reconvened at their normally scheduled team meeting times and the MI Appraisal Inventory was repeated.
Evaluation of Intervention Initially, the nurses were hesitant to use this new communication skill. The group was tentative with the role-play, commenting that it felt awkward. They remarked that it seemed “unnatural” and “left too much to the patient.” Assurance was given that comments such as these were not uncommon on initial implementation of MI. In fact, it was shared with the groups that the initial “reprogramming” was the most difficult barrier for nurses (Söderlund et al., 2008). After the one-on-one “ride-along” sessions, it appeared to the project manager that the nurses were gaining comfort with MI and were using it in their nurse–patient interactions. Questions were posed of the project manager during the one-onone sessions. The overall theme of the questions was related to allowing patients to verbalize resistance, and the nurse to then roll with that resistance (Dart, 2011). The need for the change to be patient-centered and not nurse-directed communication was reiterated. The project manager demonstrated the communication style as often as possible during the one-on-one time, as a means of guiding the nurses. As the implementation continued and the nurses had more time to use this style, and as the group began to develop a unified spirit of MI, they started to gain comfort with MI and the ability to allow the patient to direct their healing or behavior change. As the end of the project implementation neared, the nurses requested additional one-on-one time, which was granted. This additional time offered the program manager the opportunity to reaffirm the skills introduced and address any skepticism that was formed during the implementation.
Home Healthcare Now
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
81
The implementation of MI education for home healthcare nurses providing care to chronically ill patients achieved its aim to increase the communication self-efficacy of the nurses with regard to MI use.
Pretest means of motivational interviewing self-efficacy by site Rural site
52.6
Urban site
52.7
0 4 8 12 16 20 24 28 32 36 40 44 48 52 56 60 64 68
Total possible score
Results Combined site pretest scores ranged from 42 to 66 (n = 20) and posttest scores ranged from 56 to 72 (n = 20). Descriptive statistics of the pretest and posttest score results revealed that the difference between the means increased by 25% indicating a successful evidence-based practice (EBP) change project (Table 1). Norgaard et al. (2012) found that an increase of 18% in self-efficacy, as a result of a communication education, yielded long-lasting gains in communication selfefficacy among healthcare professionals in the clinical setting. At the initiation of the project, the two sites represented little difference in knowledge and selfefficacy of MI among the nurses. Pretest scores, at the rural site, ranged from 42 to 62 (n = 10), out of 76 possible points, M = 52.6 (SD = 6.95). The urban site’s scores ranged from 43 to 66 (n = 10) (SD = 7.5) (Figure 1). These scores indicated an overall similar self-efficacy of MI at both sites, though the range of self-efficacy of the nurses was greater at the urban site. Posttest scores, however, revealed an increase in the overall knowledge and self-efficacy of the nurses at both sites. The posttest mean of the rural site (n = 10) was M = 67.2 (SD = 4.7). These outcome, descriptive statistics were greater than that of the urban site M = 64.6 (SD = 4.9) (Figure 2). The increase from pretest
Table 1. Comparison of Descriptive Statistics of Pretest and Posttest Scores Descriptive Statistic
n
Pretest
Posttest
Mean
20
52.6
65.9
Median
20
51.0
67.0
Mode
20
49.0
70.0
Standard deviation
20
7.0
4.9
Range
20
24.0
16.0
82
Volume 33
|
Number 2
Figure 1. Mean test scores, out of 76 possible points, as differentiated by site.
Pretest means of motivational interviewing self-efficacy by site Rural site
67.2
Urban site
64.6
0 4 8 12 16 20 24 28 32 36 40 44 48 52 56 60 64 68
Total possible score Figure 2. Mean posttest scores, out of a 76 possible points, as differentiated by site.
to posttest for the rural site was 27.5%, as compared with that of the urban site increase of 22.8%. The overall increase of mean scores, from pretest to posttest, indicated an increase in the understanding and self-efficacy of the nurses as it is related to their MI use. The 25% increase in the nurses’ self-efficacy noted between the pretest and the posttest scores demonstrated the overall effectiveness of the EBP change. A t-test was calculated, t(34) = 6.92; p < 0.001 representing the statistical significance of this EBP change.
Discussion The implementation of MI education for home healthcare nurses providing care to chronically ill patients achieved its aim to increase the communication self-efficacy of the nurses with regard to MI use. Like the findings of Goldstein et al. (1998), however, the nurses’ initial reaction was one of skepticism. However, with
www.homehealthcarenow.org
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Patient-centered care requires nurses to engage the patients in involvement of their own care. a small amount of practice, the nurses were able to interweave this communication style into their daily practice. They commented that initially the implementation was difficult and they often would forget, but that the use of the daily record acted as a reminder to use MI. After 2 weeks approximately half of the nurses had incorporated its use, especially with patients identified as difficult to convince to adopt healthy behaviors. The remaining half expressed increased comfort after the program manager’s ride-along, during which the program manager demonstrated use of MI. The two geographically different groups of nurses expressed similar experiences with the implementation. Although the demographics of the populations served were somewhat different, the nurses themselves were not. The implementation was similar in both settings; however, the nurses in the rural setting did not serve as many patients per nurse, and thus there were fewer opportunities for practice. The nurses reported that as they used MI, it became easier and more natural. Many nurses verbalized an increase in ownership of positive behaviors in their chronically ill patients. The institution’s administration remained helpful and eager to assist throughout the implementation. Direct nursing managers have been educated regarding MI and will continue to provide education to new staff. Limitations of this project included the limited time available to provide education to the staff. A 6-hour education or a series of educational opportunities with more time for role-play would have provided the nurses with a greater foundation in MI. Additionally, the caseload held by each nurse varied significantly and this altered some of the nurses’ ability to embrace the spirit and use of MI in practice. The study sample was small with participants residing in two areas of one state. Finally, the nurses were all white and mostly female, making it difficult to generalize findings. Offering nurses MI education represents a significant fiscal opportunity for healthcare
February 2015
organizations. Overall project cost, considering implementer salary, would be approximately $6,124 for the MI education of 20 nurses. A single 5-day rehospitalization, within a 30-day window, can burden an organization with the absorption of approximately $9,800 (Henry J. Kaiser Family Foundation, 2011). At a cost much greater than the one-time education, the value of the education will grow exponentially with each 30-day rehospitalization prevented. The increase in communication self-efficacy of nurses has far-reaching effects. Increases in communication self-efficacy of the nurses will yield more patient-centered care and less nursedirected care. This in turn can lead to positive outcomes for the patients served, and may ultimately lead to a decrease in rehospitalization. Joni J. Pyle, DNP, RN, is an Instructor, Pennsylvania College of Technology, Williamsport, Pennsylvania. The author declares no conflicts of interest. Address for correspondence: Joni J. Pyle, DNP, RN, 1517 Walnut St., Williamsport, PA 17701 ([email protected]). DOI:10.1097/NHH.0000000000000184
REFERENCES American Nurses Association. (2014). Home Health Nursing: Scope and Standards of Practice (2nd ed.). Silver Spring, MD: Nursebooks.org Borrelli, B., Riekert, K. A., Weinstein, A., & Rathier, L. (2007). Brief motivational interviewing as a clinical strategy to promote asthma medication adherence. Journal of Allergy and Clinical Immunology, 120(5), 1023-1030. Dart, M. (2011). Motivational Interviewing in Nursing, Empowering the Patient. Sudbury, MA: Jones and Bartlett. Goldstein, M. G., DePue, J. D., Monroe, A. D., Lessne, C. W., Rakowski, W., Prokhorov, A., …, Dubé, C. E. (1998). A population-based survey of physician smoking cessation counseling practices. Preventive Medicine, 27(5 Pt 1), 720-729. Henry J. Kaiser Family Foundation. (2011). Hospital adjusted expensed pre- inpatient day. Retrieved from http://kff.org/other/ stateindicator/expenses-per-inpatient-day/ Institute for Healthcare Communication. (2011). Impact of communication in healthcare. Retrieved from http://healthcarecomm.org/ about-us/impact-of-communication-in-healthcare/ Miller, W., & Rollnick, S., (2013). Motivational Interviewing: Helping People Change. New York, NY: Guillford Press. Miller, W., Rollnick, S., & Butler, C. (2008). Motivational Interviewing in Health Care: Helping Patients Change Behavior. New York, NY: Guilford Press. Nørgaard, B., Ammentorp, J., Ohm Kyvik, K., & Kofoed, P. E. (2012). Communication skills training increases self-efficacy of health care professionals. Journal of Continuing Education in the Health Professions, 32(2), 90-97. Rollnick, S., & Miller, W. R. (1995). What is motivational interviewing? Behavioral and Cognitive Psychotherapy, 23, 325-332. Söderlund, L. (2010). Motivational interviewing in theory and practice. Retrieved from http://www.divaportal.org/smash/get/ diva2:356212/FULLTEXT01 Söderlund, L., Nilsen, P., & Kristensson, M. (2008). Learning motivational interviewing: Exploring primary health care nurses’ training and counseling experiences. Health Education Journal, 67(2), 102-109.
Home Healthcare Now
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83
A Motivational Interviewing Education Intervention for Home Healthcare Nurses The ability of registered nurses to communicate well with their patients is foundational to patient-centered care, the management of chronic illness, and general healthcare. It is also vital to the nurse–patient relationship. Nurses, however, tend to identify with their patients’ physical needs and rely heavily on the technical skills with which they feel more comfortable. This lack of ability to communicate well with their patients can result in poor nurse–patient understanding, can lead to poor patient outcomes, and a lack of patient engagement and involvement in their care. Motivational interviewing (MI), a patient-centered manner of communication, is a means to direct the nurse–patient interaction in a way that is patient centered. Brief education of MI has shown to be effective in increasing the self-efficacy of nurses in their ability to communicate well with their patients. In 2 geographically diverse Pennsylvania home care settings, MI education was provided to 20 nurses. The educational intervention was designed to increase the self-efficacy of nurses regarding their ability to affect the negative behaviors of chronically ill patients. A pretest and posttest was administered to the nurse participants to determine the effectiveness of the educational intervention. This evidence-based education increased the nurses’ overall communication self-efficacy by 25%.
February 2015
Joni J. Pyle, DNP, RN
N
urses are tasked to communicate with and educate patients regarding their medical conditions, their treatments, and the behavior changes that can lead to health and well-being. This requires nurses to gain an appreciation of an individual’s physical, emotional, spiritual, and social needs. Interactions of this nature require nurses to have a sound ability to communicate well with those for whom care is provided. Good communication skills practiced by nurses can positively affect patient satisfaction, safety, and patient adherence to their plan of care (Institute for Healthcare Communication, 2011). Motivational interviewing (MI), a patient-centered manner
Home Healthcare Now
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
79
Motivational interviewing, a patientcentered manner of communication, has been suggested as a means to direct the nurse–patient interaction in such a way that communication becomes patient centered.
of communication, has been suggested as a means to direct the nurse–patient interaction in a way that communication becomes patientcentered. It has been found that creating a patient-centered environment enhances the overall patient experience, and patient outcomes (Borrelli et al., 2007). MI encourages self-care and promotes behavior changes by enhancing patient-centered care (Dart, 2011). Patientcentered care requires nurses to engage patients in involvement of their own care. Nurses need communication skills that encourage this patient-centeredness as healthcare shifts to the management of long-term chronic illness and the encouragement of healthier lifestyles, each of which requires active participation by the patient. In fact, the Home Health Nursing Scope and Standards of Practice (American Nurses Association, 2014) charges that the home healthcare registered nurse “develops communication skills that promote behavior change in patients, such as the use of motivational interviewing, counseling, and health coaching communication techniques” (p. 67). MI is a technique that can be learned; however, it is also considered a “spirit” that at its core elicits a patient’s motivation for positive change (Miller et al., 2008). The authors add that it is a way of guiding patients instead of directing; patient autonomy is highly respected. Although this practice is not counter to what nurses currently do, it is a shift in control from that of the nurse to that of the patient. A review of the literature found MI to be effective in helping nurses to more successfully talk with patients (Dart, 2011; Miller & Rollnick, 2013; Rollnick & Miller, 1995). A survey of MItrained nurses found that 91% of nurses with MI knowledge found MI to be easy to use, as well as in alignment with nursing’s theoretical foundation (Söderlund, 2010). Goldstein et al. (1998)
80
Volume 33
|
Number 2
asserted that nurses often initially have difficulty employing MI because they have been trained to offer advice as part of their nursing education. Nurses are, nevertheless, successful with learning and implementing MI. Norgaard et al. (2012) conducted an investigation of 181 healthcare professionals of varying disciplines finding that providing communication skills education increased the self-efficacy of healthcare professionals, as it is associated with patient-centered communication. The literature supports the use of MI in healthcare and its use by the nursing discipline as a means to create a patient-centered delivery of care.
Purpose of the Project In a regional medical center in Pennsylvania, nursing administration found that nursing communication was lacking. It was identified that nurses receive little education directly related to communication with chronically ill patients. Additionally, it was recognized that no communication support was provided to this group of nurses. The institution was anxious to engage in the provision of an educational intervention of MI for its home care nursing staff, as the organization realized the overall benefits of good nurse–patient communication. The question guiding this evidence-based education project was: does providing brief MI education increase nurses’ communication self-efficacy and positively affect their ability to motivate positive change among their chronically ill patients?” It was anticipated that the MI education would increase the self-efficacy of nurses regarding communication with their patients; hence, more significant patient-centered care would take place. This practice would then encourage patients’ increased engagement, greater involvement in their care, and ultimately better healthcare outcomes.
Method The organization’s institutional review board approved this project. The author developed the MI Appraisal Inventory, consisting of a 19-question Likert scale questionnaire, to measure nurses’ understanding and self-efficacy related to the use of MI. Three advanced practice nurses with knowledge of nurse communication and MI reviewed the tool for face validity. The inventory was delivered as a pretest and
www.homehealthcarenow.org
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
a posttest to ascertain if the education intervention resulted in an increase in nurse selfefficacy regarding MI. Setting
The education intervention took place at two geographically diverse locations of the home care agency of a regional medical center in central Pennsylvania. One site was urban and suburban, and the other rural. Ten nurses at each site agreed to participate. All 20 participants were white. In the urban/suburban group, there were nine females and one male, whereas all nurses in the rural group were female. All of the participants had at least 1 year of experience as a registered nurse, but their experience in home care varied. Education of the nurses participating in the project also differed from associate in nursing to master’s in nursing, although the majority of nurses held a nursing associate degree. Intervention
During a normally scheduled team meeting, a 2-hour education session regarding MI use with chronically ill patients was undertaken. Nurses were asked to complete the MI Appraisal Inventory before the education was initiated. The author created a booklet, the Motivational Interviewing Guide, complete with MI information and tools to enhance its use. A copy was given to each nurse to us,e and copies of Motivational Interviewing in Nursing Practice: Empowering the Patient (Dart, 2011) were given to the nurse managers for use as a reference. A presentation including MI background, information regarding the spirit of MI, the principles on which MI is based, the process of MI, and the skills and techniques of MI was conducted with 10 nurses at the urban/suburban location. Tools that nurses might use with their patients during MI use, contained in the Motivational Interviewing Guide, were highlighted and their use explained. An opportunity for questions was presented, and then the group engaged in active role-play providing an opportunity for practice. Finally, nurses were introduced to a form that provided them with the ability to track their daily use of MI principles. The education was repeated, in the same manner, with 10 nurses at the rural location. During the 8 weeks immediately after the education intervention, the project manager
February 2015
contacted each of the nurses and arranged an opportunity to ride-along with the nurse to observe the nurse’s interaction with their patients and their use of MI with those patients. After each nurse–patient interaction, an opportunity for one-on-one questions and debriefing was provided. Feedback provided to the nurse was private, individualized, and aimed at increasing the self-efficacy of use of MI in their daily practice. Following 8 weeks of MI use, the nurses were reconvened at their normally scheduled team meeting times and the MI Appraisal Inventory was repeated.
Evaluation of Intervention Initially, the nurses were hesitant to use this new communication skill. The group was tentative with the role-play, commenting that it felt awkward. They remarked that it seemed “unnatural” and “left too much to the patient.” Assurance was given that comments such as these were not uncommon on initial implementation of MI. In fact, it was shared with the groups that the initial “reprogramming” was the most difficult barrier for nurses (Söderlund et al., 2008). After the one-on-one “ride-along” sessions, it appeared to the project manager that the nurses were gaining comfort with MI and were using it in their nurse–patient interactions. Questions were posed of the project manager during the one-onone sessions. The overall theme of the questions was related to allowing patients to verbalize resistance, and the nurse to then roll with that resistance (Dart, 2011). The need for the change to be patient-centered and not nurse-directed communication was reiterated. The project manager demonstrated the communication style as often as possible during the one-on-one time, as a means of guiding the nurses. As the implementation continued and the nurses had more time to use this style, and as the group began to develop a unified spirit of MI, they started to gain comfort with MI and the ability to allow the patient to direct their healing or behavior change. As the end of the project implementation neared, the nurses requested additional one-on-one time, which was granted. This additional time offered the program manager the opportunity to reaffirm the skills introduced and address any skepticism that was formed during the implementation.
Home Healthcare Now
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
81
The implementation of MI education for home healthcare nurses providing care to chronically ill patients achieved its aim to increase the communication self-efficacy of the nurses with regard to MI use.
Pretest means of motivational interviewing self-efficacy by site Rural site
52.6
Urban site
52.7
0 4 8 12 16 20 24 28 32 36 40 44 48 52 56 60 64 68
Total possible score
Results Combined site pretest scores ranged from 42 to 66 (n = 20) and posttest scores ranged from 56 to 72 (n = 20). Descriptive statistics of the pretest and posttest score results revealed that the difference between the means increased by 25% indicating a successful evidence-based practice (EBP) change project (Table 1). Norgaard et al. (2012) found that an increase of 18% in self-efficacy, as a result of a communication education, yielded long-lasting gains in communication selfefficacy among healthcare professionals in the clinical setting. At the initiation of the project, the two sites represented little difference in knowledge and selfefficacy of MI among the nurses. Pretest scores, at the rural site, ranged from 42 to 62 (n = 10), out of 76 possible points, M = 52.6 (SD = 6.95). The urban site’s scores ranged from 43 to 66 (n = 10) (SD = 7.5) (Figure 1). These scores indicated an overall similar self-efficacy of MI at both sites, though the range of self-efficacy of the nurses was greater at the urban site. Posttest scores, however, revealed an increase in the overall knowledge and self-efficacy of the nurses at both sites. The posttest mean of the rural site (n = 10) was M = 67.2 (SD = 4.7). These outcome, descriptive statistics were greater than that of the urban site M = 64.6 (SD = 4.9) (Figure 2). The increase from pretest
Table 1. Comparison of Descriptive Statistics of Pretest and Posttest Scores Descriptive Statistic
n
Pretest
Posttest
Mean
20
52.6
65.9
Median
20
51.0
67.0
Mode
20
49.0
70.0
Standard deviation
20
7.0
4.9
Range
20
24.0
16.0
82
Volume 33
|
Number 2
Figure 1. Mean test scores, out of 76 possible points, as differentiated by site.
Pretest means of motivational interviewing self-efficacy by site Rural site
67.2
Urban site
64.6
0 4 8 12 16 20 24 28 32 36 40 44 48 52 56 60 64 68
Total possible score Figure 2. Mean posttest scores, out of a 76 possible points, as differentiated by site.
to posttest for the rural site was 27.5%, as compared with that of the urban site increase of 22.8%. The overall increase of mean scores, from pretest to posttest, indicated an increase in the understanding and self-efficacy of the nurses as it is related to their MI use. The 25% increase in the nurses’ self-efficacy noted between the pretest and the posttest scores demonstrated the overall effectiveness of the EBP change. A t-test was calculated, t(34) = 6.92; p < 0.001 representing the statistical significance of this EBP change.
Discussion The implementation of MI education for home healthcare nurses providing care to chronically ill patients achieved its aim to increase the communication self-efficacy of the nurses with regard to MI use. Like the findings of Goldstein et al. (1998), however, the nurses’ initial reaction was one of skepticism. However, with
www.homehealthcarenow.org
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Patient-centered care requires nurses to engage the patients in involvement of their own care. a small amount of practice, the nurses were able to interweave this communication style into their daily practice. They commented that initially the implementation was difficult and they often would forget, but that the use of the daily record acted as a reminder to use MI. After 2 weeks approximately half of the nurses had incorporated its use, especially with patients identified as difficult to convince to adopt healthy behaviors. The remaining half expressed increased comfort after the program manager’s ride-along, during which the program manager demonstrated use of MI. The two geographically different groups of nurses expressed similar experiences with the implementation. Although the demographics of the populations served were somewhat different, the nurses themselves were not. The implementation was similar in both settings; however, the nurses in the rural setting did not serve as many patients per nurse, and thus there were fewer opportunities for practice. The nurses reported that as they used MI, it became easier and more natural. Many nurses verbalized an increase in ownership of positive behaviors in their chronically ill patients. The institution’s administration remained helpful and eager to assist throughout the implementation. Direct nursing managers have been educated regarding MI and will continue to provide education to new staff. Limitations of this project included the limited time available to provide education to the staff. A 6-hour education or a series of educational opportunities with more time for role-play would have provided the nurses with a greater foundation in MI. Additionally, the caseload held by each nurse varied significantly and this altered some of the nurses’ ability to embrace the spirit and use of MI in practice. The study sample was small with participants residing in two areas of one state. Finally, the nurses were all white and mostly female, making it difficult to generalize findings. Offering nurses MI education represents a significant fiscal opportunity for healthcare
February 2015
organizations. Overall project cost, considering implementer salary, would be approximately $6,124 for the MI education of 20 nurses. A single 5-day rehospitalization, within a 30-day window, can burden an organization with the absorption of approximately $9,800 (Henry J. Kaiser Family Foundation, 2011). At a cost much greater than the one-time education, the value of the education will grow exponentially with each 30-day rehospitalization prevented. The increase in communication self-efficacy of nurses has far-reaching effects. Increases in communication self-efficacy of the nurses will yield more patient-centered care and less nursedirected care. This in turn can lead to positive outcomes for the patients served, and may ultimately lead to a decrease in rehospitalization. Joni J. Pyle, DNP, RN, is an Instructor, Pennsylvania College of Technology, Williamsport, Pennsylvania. The author declares no conflicts of interest. Address for correspondence: Joni J. Pyle, DNP, RN, 1517 Walnut St., Williamsport, PA 17701 ([email protected]). DOI:10.1097/NHH.0000000000000184
REFERENCES American Nurses Association. (2014). Home Health Nursing: Scope and Standards of Practice (2nd ed.). Silver Spring, MD: Nursebooks.org Borrelli, B., Riekert, K. A., Weinstein, A., & Rathier, L. (2007). Brief motivational interviewing as a clinical strategy to promote asthma medication adherence. Journal of Allergy and Clinical Immunology, 120(5), 1023-1030. Dart, M. (2011). Motivational Interviewing in Nursing, Empowering the Patient. Sudbury, MA: Jones and Bartlett. Goldstein, M. G., DePue, J. D., Monroe, A. D., Lessne, C. W., Rakowski, W., Prokhorov, A., …, Dubé, C. E. (1998). A population-based survey of physician smoking cessation counseling practices. Preventive Medicine, 27(5 Pt 1), 720-729. Henry J. Kaiser Family Foundation. (2011). Hospital adjusted expensed pre- inpatient day. Retrieved from http://kff.org/other/ stateindicator/expenses-per-inpatient-day/ Institute for Healthcare Communication. (2011). Impact of communication in healthcare. Retrieved from http://healthcarecomm.org/ about-us/impact-of-communication-in-healthcare/ Miller, W., & Rollnick, S., (2013). Motivational Interviewing: Helping People Change. New York, NY: Guillford Press. Miller, W., Rollnick, S., & Butler, C. (2008). Motivational Interviewing in Health Care: Helping Patients Change Behavior. New York, NY: Guilford Press. Nørgaard, B., Ammentorp, J., Ohm Kyvik, K., & Kofoed, P. E. (2012). Communication skills training increases self-efficacy of health care professionals. Journal of Continuing Education in the Health Professions, 32(2), 90-97. Rollnick, S., & Miller, W. R. (1995). What is motivational interviewing? Behavioral and Cognitive Psychotherapy, 23, 325-332. Söderlund, L. (2010). Motivational interviewing in theory and practice. Retrieved from http://www.divaportal.org/smash/get/ diva2:356212/FULLTEXT01 Söderlund, L., Nilsen, P., & Kristensson, M. (2008). Learning motivational interviewing: Exploring primary health care nurses’ training and counseling experiences. Health Education Journal, 67(2), 102-109.
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