ORIGINAL ARTICLE

District nurses’ and registered nurses’ training in and use of motivational interviewing in primary care settings € Ann-Sofi Ostlund, Barbro Wadensten, Elisabeth H€ aggstr€ om and Marja-Leena Kristofferzon

Aims and objectives. To examine to what extent district nurses and registered nurses have training in motivational interviewing, to what extent they use it and what prerequisites they have for using it; to compare district nurses and registered nurses, as well as to compare users and nonusers of motivational interviewing; and to examine possible relationships between use of motivational interviewing and the variables training, supervision and feedback in motivational interviewing and prerequisites for use. Background. Motivational interviewing is an effective method for motivating patients to change their lifestyle, used increasingly in primary care. Design. A cross-sectional survey study. Methods. A study-specific questionnaire was sent to all district nurses and registered nurses (n = 980) in primary care in three counties in Sweden, from September 2011–January 2012; 673 (69%) responded. Differences between groups as well as relationships between study variables were tested. Results. According to self-reports, 59% of the respondents had training in motivational interviewing and 57% used it. Approximately 15% of those who reported using it had no specific training in the method. More district nurses than registered nurses had training in motivational interviewing and used it. The following factors were independently associated with the use of motivational interviewing: training in and knowledge of motivational interviewing, conditions for using it, time and absence of ‘other’ obstacles. Conclusions. Having knowledge in motivational interviewing and personal as well as workplace prerequisites for using it may promote increased use of motivational interviewing. Relevance to clinical practice. Having the prerequisites for using motivational interviewing at the workplace is of significance to the use of motivational interviewing. In the context of primary care, district nurses seem to have better prerequisites than registered nurses for using motivational interviewing.

What does this paper contribute to the wider global clinical community?

• It is of importance that all regis-





tered nurses understand/know that motivational interviewing is essential in all meetings/interactions with patients and is not reserved only for special interaction. All registered nurses need to reconsider their communication style and take responsibility to gain experience in using motivational interviewing after undergoing training in motivational interviewing. Employers need to provide the necessary prerequisites and support for use of motivational interviewing.

Key words: education, health promotion, motivational interviewing, nurses, primary health care, training Accepted for publication: 22 September 2013 ¨ stlund, RN, PhD Student, Department of Public Authors: Ann-Sofi O Health and Caring Sciences, Uppsala University, Uppsala and Faculty of Health and Occupational Studies, University of G€ avle, G€avle; Barbro Wadensten, PhD, RN, Associate Professor, Department of Public Health and Caring Sciences, Uppsala University, Uppsala; Elisabeth Ha¨ggstro¨m, PhD, RNT, Associate Professor, Faculty of Health and Occupational Studies, University of G€ avle, G€avle and Department of Public Health and Caring Sciences,

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Uppsala University, Uppsala; Marja-Leena Kristofferzon, PhD, RNT, Senior Lecturer in Nursing, Faculty of Health and Occupational Studies, University of G€ avle, G€ avle and Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden € Correspondence: Ann-Sofi Ostlund, PhD Student, Department of Public Health and Caring Sciences, Uppsala University, BMC, Box 564, Uppsala 751 22, Sweden. Telephone: +46 26 645010. E-mail: [email protected]

© 2013 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 2284–2294, doi: 10.1111/jocn.12509

Original article

Introduction Motivational interviewing (MI) is an effective method for behavioural change (Hettema et al. 2005, Rubak et al. 2005) that is being used increasingly in many different healthcare settings (Lundahl & Burke 2009, Madson et al. 2009). Following recommendations for use of MI in Swedish public health policy, there has been increased education in and use of the method in primary care (The Swedish Government 2008). Therefore, it is interesting to investigate how spread use of MI is, that is, how many district nurses (DNs) and registered nurses (RNs) have received training in MI and when and to what extent they use MI in their work.

Background Heart disease, stroke, cancer, chronic respiratory diseases and diabetes are major causes of mortality worldwide. Common underlying and preventable risk factors include tobacco use, harmful consumption of alcohol, unhealthy diet and physical inactivity, overweight/obesity, high blood pressure, high blood glucose and high cholesterol. Eighty per cent of heart disease and stroke, 90% of type 2 diabetes and 30% of all cancer can be prevented through healthy diet, cessation of smoking and sufficient physical activity [World Health Organization (WHO) 2012]. In Sweden, 18% of men and 14% of women smoke, and during the past decade, alcohol consumption and overweight/obesity have increased, while everyday physical activity has decreased [The Swedish Board of Health and Welfare (SBHW) 2010]. Health is a human right, and the ultimate goal of global health policy is to achieve full health for everyone. Primary care and prevention are keys to achieving this goal (WHO 1978, WHO Europe 2006). MI is one measure suggested in guidelines for disease prevention (WHO 2010, SBHW 2011). MI is a directive, patient-centred counselling style that explores and resolves ambivalence so as to increase patient motivation for change (Miller & Rollnick 2002). MI has been shown to be effective in changing many aspects of lifestyle, such as diet, exercise, smoking, alcohol abuse and diabetes (Hettema et al. 2005, Rubak et al. 2005, Martins & McNeil 2009). The spirit of MI is collaboration, evocation and autonomy, and the four guiding principles in MI are to express empathy, develop discrepancy, roll with resistance and support self-efficacy. MI encourages patients to make their own choices, identify their lifestyle problems and identify their own ability to make a change as well as their own solutions. The therapist’s role is to direct and support, © 2013 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 2284–2294

Nurses’ use of motivational interviewing

while treating the patient as an equal (Miller & Rollnick 2002). Sweden has 20 county councils, which are the entities responsible for health care [Swedish Association of Local Authorities and Regions (SALAR) 2011]. The foundation of county council health and medical care is primary care, to which citizens primarily turn with questions about their health. Primary care centres also work with health promotion, where the focus is on population lifestyle (Glenng ard et al. 2005). In Sweden, primary care has 93,600 visits each day (not including visits to physicians; SALAR 2011), and DNs and RNs play an important role, as many patients’ first contact with the healthcare system is with a nurse (Glenng ard et al. 2005, WHO 2010). District nurses have an advanced specialist education suited to primary care as well as in-depth knowledge in the areas of public health and health promotion (The Association of Swedish District Nurses (DSF) 2008, Nursing & Midwifery Council UK 2010). RNs do not have the specialist/in-depth education in health promotion that DNs do, but RNs do hold the same positions, which may require work with health promotion. It is also stated in their competence description (SBHW 2005) that they should have the ability to promote health, and the Swedish National guidelines for disease-preventive methods are addressed to all healthcare personnel (SBHW 2011). According to the National Assembly for Wales (NAfW 2001), assessment of health needs, health education and health promotion requires the expertise and knowledge of a higher grade nurse and cannot be delegated to different nursing grades as can other nursing assignments. The various disciplines of nursing constitute specialist elements that cannot easily be taken over by other disciplines. It is these elements that make the contributions of specialist nurses unique. The specialist skills that DNs offer to, for example, health promotion must continue to be recognised and promoted. Motivational interviewing is an effective method now being used to help patients change their lifestyle (Rubak et al. 2005, Martins & McNeil 2009), and primary care nurses play an important role in the health promotion (WHO Europe 2006, Irvine 2007). Primary care personnel in Sweden are being educated in MI to facilitate health promotion work with patients (The Swedish Government 2008), but it is unclear how many nurses actually use it and what their prerequisites for using it are. The MI training offered varies from two- to four-day short courses arranged by county councils to university courses lasting several weeks. The question is: ‘Is there reason to believe that DNs more easily embrace a preventive method such

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as MI after short training than RNs do, because DNs are specialised in health promotion and primary care?’ As shown in previous research, primary care settings are characterised by time constraints and a large number of patients (Velasquez et al. 2000, Resnicow et al. 2002). It is also a challenge to learn new techniques and to refrain from previous ingrained habits (Resnicow et al. 2002). It has been suggested in the literature (Miller et al. 2004, Forsberg et al. 2011) that there is need for continuous supervision and feedback in relation to MI in order to increase and maintain use of MI after training. Thus, the aim of this study was to examine to what extent DNs and RNs have training in MI, to what extent they use MI and what prerequisites they have for using MI. Given this aim, it was also of interest to compare the two groups, DNs and RNs, as well as to compare those who used and those who did not use MI. Further, we found it relevant to examine possible relationships between use of MI and the variables MI training, supervision, feedback and prerequisites for using MI.

Research questions 1 To what extent are DNs and RNs in primary care trained in MI and, if they are, when and to what extent do they use MI in their work and are there any differences between DNs and RNs? 2 What prerequisites do DNs and RNs in primary care indicate they have for using MI and are there any differences between DNs and RNs? 3 Are there any differences in background characteristics, training and prerequisites between users and nonusers of MI? 4 What relationships are there between use of MI and the variables training, supervision, feedback and prerequisites in the study group?

Methods Design, sample and settings This study was a cross-sectional survey study. Total sampling of all DNs and RNs working in primary care in three counties in central Sweden was used. Three counties were chosen so as to obtain a large and varied sample of nurses from different settings, both urban and rural. The inclusion criteria were DNs and RNs who were currently employed and working with adults (including parents visiting DNs and RNs at the child health surgery) in somatic primary care. The total sample consisted of 980 DNs and

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RNs from 91 primary care centres and DN surgeries run by the county council. The included counties have 891,325 citizens [Statistics Sweden (SCB) 2011]. In these three counties, there was a large university town, several larger and smaller towns, but also rural areas with small communities.

Data collection Data were collected, from September 2011–January 2012, using a study-specific, self-report questionnaire containing 27 questions divided into three topics. Background characteristics contained four questions on gender, age and education in nursing. Training and use of MI included 10 questions on training, supervision and feedback related to MI and six questions on use of MI. Prerequisites covered seven questions about conditions for and obstacles to using MI, confidence in and opinions about MI. Different types of response alternatives were used in the questionnaire, such as dichotomous, four-, five- or six-graded scales, questions with different or multiple choices and two of the questions were open-ended. The respondents also had the opportunity to make comments. The questionnaire was based on expert advice from researchers in the area of MI and MI training, literature reviews (Resnicow et al. 2002, Miller et al. 2004, Mitcheson et al. 2009, Forsberg et al. 2011) and the first author’s own expertise based on observations in the field (Polit & Beck 2012). Face and content validity were addressed by asking six DNs and one RN whether they understood the questions, response alternatives and instructions. They were also asked to rate each question on a five-point scale of relevance (1 = low relevance to 5 = high relevance; Polit & Beck 2012). The nurses (DNs and RNs) were between 35–64 years of age and had worked as a nurse from 9–35 years. Four had training in MI and three did not. Concerning face validity, all questions were understood. As regards the content validity of the questions, three of the nurses experienced that all questions were relevant. Four nurses experienced some difficulties with three to 10 questions because the answers were difficult to remember. Local authorities at each unit in primary care in the three counties were contacted by email and/or telephone to receive the names of all DNs and RNs fulfilling the inclusion criteria. The questionnaire, information about the study and a stamped return envelope were then sent by post to all DNs and RNs, at their respective workplaces. Two reminders were sent at about a two-week interval. The answered questionnaire was returned to the first author by post, in the stamped return envelope. © 2013 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 2284–2294

Original article

Data analysis All analyses were conducted using IBM SPSS Statistics, version 20 (IBM Corp., Armonk, NY, USA). Two respondents did not indicate whether they were DNs or RNs and were therefore excluded from analyses of differences between DNs and RNs. Descriptive statistics were computed for all variables and were described using means and standard deviations (SDs) for continuous variables, and frequencies and percentages for categorical variables. The ordinal variables were treated as categorical variables in the analysis. To test the differences between DNs and RNs as well as between users and nonusers of MI, independent two-tailed Student’s t-test was used for continuous variables and chi-square tests for categorical variables. Fisher’s exact test was used when one or more of the expected values were

District nurses' and registered nurses' training in and use of motivational interviewing in primary care settings.

To examine to what extent district nurses and registered nurses have training in motivational interviewing, to what extent they use it and what prereq...
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