BRIEF REPORT

Teaching motivational interviewing to nurse practitioner students: A pilot study Bonnie J. Nesbitt, ANP-BC, PhD (Director, Master of Science in Nursing Program), Debra A. Murray, PsyD (Director, Master of Science in Mental Health Counseling Program), & Angela R. Mensink, BS (Research Assistant) Viterbo University, La Crosse, Wisconsin

Keywords Behavior modification; coaching; role of advanced practice nurse; motivational interviewing; evidence-based practice; health promotion; lifestyle. Correspondence Bonnie J. Nesbitt, ANP-BC, PhD, Viterbo University, 900 Viterbo Drive, La Crosse, WI 54601. Tel: 608-796-3688; Fax: 608-796-3668; E-mail: [email protected] Received: August 2011; accepted: April 2012 doi: 10.1002/2327-6924.12041

Abstract Purpose: This quasi-experimental study examined the outcomes of a brief educational module for graduate nursing students as to using motivational interviewing (MI)-consistent counseling skills. Data sources: Pre- and posttest narrative and video-taped data, surveys, and self-report. Conclusions: Significantly fewer closed questions, more open questions, and less advice-giving without permission were noted in the narratives completed after the education. Similarly, the second videotape revealed significantly more affirmations, use of reflections, and use of more summaries when ending patient sessions. Surveys and self-report indicated strong satisfaction with the opportunity to learn MI. Implications for practice: A core competency of nurse practitioner (NP) education involves helping persons adopt positive health behaviors. While research utilizing MI has evidenced substantial success in this regard, little has been published as to how to incorporate teaching this skill set within an already content-laden NP curriculum. Including at least minimal education in MI should occur in NP programs. Eight hours of education, including videotaped practice, followed by ”booster sessions” to maintain skills and increase confidence is recommended. More research is necessary to elucidate best practices of teaching this skill set to NPs and its eventual outcomes on patients’ health.

One of the overarching goals of Healthy People 2020 is to “promote quality of life, healthy development, and healthy behaviors across all life stages” (U. S. Health & Human Services, 2020, p. 3). Consistent with this goal, promoting healthy behavior is an essential component of nurse practitioner (NP) practice. Assisting persons to change unhealthy behaviors may help prevent chronic disease and disability. The core competencies for NPs refer to coaching for positive behavior change as well as developing a respectful relationship with patients, allowing them some control over their plan of care (National Organization of Nurse Practitioner Faculties [NONPF], 2011). Successfully attending to this goal and meeting these competencies requires an effective approach. Motivational interviewing (MI), a counseling/ communication approach that has evidenced positive outcomes regarding behavior change, is theoretically based and philosophically congruent with the core com-

petencies of NP practice. Rubak, Sandboek, Lauritzen, and Christensen (2005), in their meta-analysis of randomized controlled studies using MI as the intervention, reported significant findings in three fourths of the 72 studies reviewed. Sixty-four percent of the studies reported a positive effect after one brief MI encounter. Their conclusion was that MI outperforms advice-giving in a wide range of healthcare situations. MI is often utilized with individuals who may be ambivalent or angry concerning a prescribed change in behavior (Miller & Rollnick, 2002; Rollnick, Miller, & Butler, 2008). The theoretical base of MI combines person-centered counseling with select social psychology theories related to communication and motivation (Murray, 2002). MI counseling approaches employ a skill set to reduce ambivalence and explore the possibility of change (Miller & Rollnick, 2002). The overall spirit of MI includes fostering collaboration, honoring autonomy,

C 2013 The Author(s) Journal of the American Association of Nurse Practitioners 26 (2014) 131–135 

 C 2013 American Association of Nurse Practitioners

131

Teaching motivational interviewing

and evoking the patient’s perspective. Skills associated with MI include the use of open-ended questions along with a reduction of close-ended questions; affirmations of the individual’s strength or motivation; reflections targeting the reduction of ambivalence; and summaries ensuring that the patient’s perspective has been accurately captured (Miller & Rollnick, 2002). The initial development of MI has roots in the substance-abuse field. It was discovered that the more individuals with drinking problems were confronted, the more they were drinking a year later (Miller, 1983). This finding spurred interest in less confrontational, less directive communication and counseling strategies. In this context, the framework of MI was developed. Soon numerous investigations applying MI were being conducted with patients having diabetes and cardiac conditions, as well as exercise, weight management, smoking cessation, and chronic pain issues (Rollnick et al., 2008). While several articles have described MI and suggested its use within nursing (Lange & Tigges, 2005; Levensky, Forcehimes, O’Donohue, & Beitz, 2007; Van Nes & Sawatzky, 2010), little has been reported on the best methods of educating healthcare professionals to utilize MI strategies. The authors of this article, a nursing professor, a psychology professor, and a research assistant, collaborated on developing a brief MI-based educational module for graduate nursing students enrolled in a core Masters-level course entitled Health Promotion/Clinical Prevention. The majority of those enrolled were NP students. This study examined the influence of this educational module on communication skills utilized to facilitate behavior change in simulated patient situations. The questions that guided this inquiry were: ■

■ ■

Do students demonstrate changes in interview style reflective of MI strategies after a brief educational module? Do students value learning MI? After training, what evidence suggests that skill acquisition was maintained or improved?

Review of the literature Use of motivational interviewing in clinical practice The use of a single MI session was found to significantly decrease the number of daily drinks in a target population within a 6-week time period, decreasing from 4.65 drinks to 1.95 drinks a day (N = 26; Beckham, 2007). In addition, liver function tests improved significantly in this group. Another study conveyed that clinicians, including a family NP, working with high-risk college students, reported that MI strategies seemed more successful in facilitating behavior change, compared to 132

B. J. Nesbitt et al.

a more directive approach, and perceived a more satisfying experience both for the students and themselves (Rash, 2008a). Obese patients (N = 58) at risk for diabetes were managed effectively through NPs’ utilization of MI within a lifestyle modification program (Whittemore et al., 2009). These authors reported that the program increased the number of patients who reached weight-loss goals (25%) in comparison to the control-group patients (11%). Trends for improved lipid levels and exercise behavior in this mixed-method study also were reported. Lastly, Perry and Bennett (2006) reported the use of MI to encourage exercise in rural women (N = 20). The program successfully increased the participants’ consistent walking behaviors. In addition, the authors, in their NP practices, related positive patient feedback with the “two-way discussion” (p. 571), rather than a one-way, cliniciandirected communication. The limitations of these studies include having small samples and lacking rigorous designs.

Teaching/learning motivational interviewing skills The review of literature revealed little information about the methods that have been utilized to teach nurses, NPs, or NP students the spirit, principles, and skills of MI. An exception was Rash (2008b), who integrated an educational module within a health promotion course for graduate nursing students. This educational module involved online synchronous chat rooms and utilized a 20-min session for a team of students to each roleplay as patient, NP, and peer reviewer. This teaching technique was enhanced by specific readings to expose the students to the principles and skills of MI. Students reported the experience was beneficial to discern helpful from unhelpful approaches for patient education/health promotion. Rash (2008a) also outlined a clinician-training program that included 8 h of initial training and supervised roleplaying with practice patients. Follow-up included audiotape reviews by a mental health counselor and feedback. In a diabetes prevention program, NPs implemented a lifestyle change program utilizing MI strategies (Whittemore et al., 2009). The training for NPs included self-study and a 45-min training videotape, followed by two 2-h workshops on MI. In addition, an expert was available for consult as needed. The authors reported that using MI was considered challenging for the NPs, who requested more extensive training. Despite this difficulty, the lifestyle change intervention program incorporating MI demonstrated more positive treatment goals than did the standard care group. Concerns expressed by NPs in using MI strategies have perceived difficulty and a lack of confidence in using MI

B. J. Nesbitt et al.

techniques (Rash, 2008a; Whittemore et al., 2009). Rash (2008a) discussed the difficulty of transitioning from previous ways of patient–provider communication to MI techniques. Breaking away from giving advice to use a more evocative method of communication was an expressed challenge. According to Rash, in spite of the challenges of using MI, clinicians reported being more focused on the patient, with the patient directing the communication. They also identified ways to incorporate MI strategies and skills into their everyday communication with patients. Educational methods used to teach MI also were described by Sargeant, Valli, Ferrier, and Macleod (2008). These authors delivered a 2-h workshop for 43 primarycare physicians after which 95.3% (N = 41) reported an intention to modify their practice accordingly. Time constraints and confidence with skills were two issues reported in follow-up interviews several months later. The authors noted that individual, education, and system issues potentially interfered with continued use of the new MI skills. MI also was implemented in a dialysis adherence study (Russell et al., 2011). The dialysis staff, including nurses, received two 2-h training sessions, followed by coaching sessions at least once a month for 3 months until proficiency was ascertained. Training was conducted before studying the outcomes of incorporating MI with this population of 29 patients receiving dialysis. The results indicated that MI training of staff had a positive influence on dialysis attendance by patients, increased frequency of shortened treatments, and improvements in some key blood chemistry levels (N = 29). MI was seen as a promising intervention. Patients verbalized positive comments about the changed communication style utilized by staff. In summary, a variety of educational methods have been reported in the literature, including independent study, workshop-style presentations, audio- and videotaped roleplay, and the use of consultants. The time that has been devoted to training also has varied, yet outcomes have been positive. If MI is to be incorporated into an already content-laden NP curriculum, it would be helpful to know how much time is needed as well as the most effective strategies to teach essential MI information efficaciously.

Methodology A one-group, quasiexperimental design with pretest and posttest written and video-recorded data was utilized. The participants were a convenience group of graduate nursing students (N = 14). Thirteen were female; the average age was 33, and all had at least 5 years of nursing experience. The health promotion/clinical prevention

Teaching motivational interviewing

course is taken in the first year of the students’ curriculum, prior to any clinical practicum experience. The intervention was a brief-educational module consisting of a 4-week exposure to MI via class lecture, discussion, video-taped practice, experiential application, and independent readings. The study was approved as exempt by the Institutional Review Board (IRB) at Viterbo University, and students signed an informed consent to participate. Before starting the MI module, a pretest was administered that asked for narrative responses to eight scenarios. This pretest was designed to assess the participants’ current, typical responses to patients with health behavior issues. Students were asked to read the scenario and to write their next likely response. The following is an example of one of the scenarios: A 23-year-old woman who smokes 1 1/2 packs a day says, “I’m getting ready to become pregnant in the next few months.” After the scenario pretest, the students were assigned readings from the text, Motivational Interviewing in Health Care: Helping Patients Change Behavior (Rollnick, Miller, & Butler, 2008), along with other articles highlighting MI’s use in health care. An asynchronous online discussion took place during the first week of the module to discuss introductory content. The following week, participants had a face-to-face 2 1/2 h class, provided by the second author. This class focused on the spirit, principles, and basic skills of MI. The first video recordings were obtained immediately after the first interactive presentation. Case scenarios with patient situation and provider goals were given to the students for the recording session. The participants worked in groups of three, with one student being the patient, one being the interviewer, and one the observer. These roles were then exchanged. Students left this class with a copy of their first videotape to review. During the third week as homework, participants reviewed their videotape using a self-assessment work sheet to note MI consistent skills and strategies and were encouraged to practice MI skills at home and at work. During week four, students were on campus for another session. The class again included 2 1/2 h of interactive lecture/discussion, demonstration, and video-recorded practice. One week after the second live-training session, participants completed a narrative posttest containing the same scenarios as the pretest. Additionally, at the conclusion of the module students were surveyed regarding the MI learning experience and their perceptions of the value and utility of using these communication strategies in nursing practice. The pre- and posttest written responses to the scenarios, the first and second video recordings for each student, as well as follow-up surveys provided the data sources. 133

Teaching motivational interviewing

Inter-rater reliability was assured amongst the three authors prior to coding the narrative and video data sources by independent rating of samples until consistency of scoring was achieved by all coders. Reliability and validity were strengthened by the fact that one author has extensive training in all aspects of MI and is a member of the MI network of trainers. The coding method included counting the use of MI skills, specifically: open-ended questions versus closed, affirmations, reflections, summaries, and advice-giving with or without permission. Furthermore, MI-related strategies such as the use of rulers and decisional balance also were noted. The use of rulers implies the use of a scale from 1 to 10 to have patients rate themselves, for example, on their perceived readiness to change (Rollnick et al., 2008). Decisional balance involves inviting the patient to relate their perceptions of costs and benefits of a behavior change (Miller & Rollnick, 2002).

Results The first research question, whether graduate nursing students demonstrated changes in interview style reflective of MI strategies after a brief-educational module, was addressed with paired t-tests to compare pre- and posttest data. In the written scenarios, significant differences were found from pre- to posttest as to fewer closed questions (t = 3.15; p = .0126) and more open questions (t = 6.78; p = .0005). Additionally there was significantly less advice-giving without permission (t = 4.382; p = .00357). From the video-tape coding, significant changes were noted from the first video to the second, including a significant increase in affirmations (t = −3.510; p = .007) and the increased use of reflections (t = −2.446; p = .029). There was a significant increase in the presence of a summary at the end of the session compared to the first video (t = −2.233; p = .044). There were increases in the use of decisional balance and ruler strategies in the post videotapes; however, these were not significant. The second research question asked if graduate nursing students valued learning MI. Evaluations indicated 100% of respondents agreed or strongly agreed that the learning was useful; 83% felt the videotaping facilitated their learning. Respondents also provided suggestions for enhancing the unit, such as more presentations, demonstrations, and follow-up sessions. The last research question asked what evidence suggests that skill acquisition was maintained or improved after training. In a follow-up survey, conducted after the students began their clinical courses, 100% reported that they used MI in their clinical practicums. Further support for the interest in MI skill acquisition was evidenced by three students attending continuing education pro134

B. J. Nesbitt et al.

grams and another conducting her master’s project on the topic.

Discussion The limitations of this study included small sample size, the lack of a control group, and the use of simulated versus authentic patient encounters. While this was a small pilot study, it offers initial support that MI communication strategies can be successfully taught to NPs when integrated into a brief-educational module of approximately eight contact hours, along with the independent activities assigned. It is reasonable to expect that NP students can learn and value at least the basics of MI’s spirit, principles, and skills. The total time expenditure, including presentations, live videotaping, and online discussion, supplemented with readings and experiential practice, seems a beneficial utilization of time, particularly given the evidence supporting MI as a successful behavior change strategy in clinic settings. Handmaker, Hester, and Delaney (1999) identified four levels of skill acquisition. The first is satisfaction feedback from participants. The second seeks measurable change in skill levels. The third examines application of the skills in clinical practice. The final level investigates change in patient behavior as a result of the training. This study addressed the first three levels of the Handmaker et al. (1999) model. Students expressed high levels of satisfaction with the training, requesting more time on the topic. Participants demonstrated increases in MI-consistent skills such as reflections, affirmations, and summaries and a reduction of advice-giving without permission. In addition, self-report indicates that many continued to use these skills in their clinical practices at least 1 year following the training. Future considerations would include investigating positive impacts in patient lifestyle change attributed to the use of MI. Whether a brief module of MI education provides sufficient skills for NPs to positively affect patient outcomes is not known. The authors suggest that MI training, similar to or more extensive than that described in this article, would be a value-added component in NP educational programs. The use of videotaping was seen as key by students and faculty, as indicated by anecdotal and postmodule survey data. In addition, based on the MI literature and student feedback, the authors recommend one or two booster training sessions during the sequence of clinical practicum courses to maintain skills, continue learning, and increase confidence. Integrating MI into NP curricula is an important first step to insure a consistent practice of this evidence-based approach to effect positive behavior changes. Faculty members in NP programs are in a strategic position to educate future NPs about the use

B. J. Nesbitt et al.

of MI to help patients make healthier choices and ultimately to potentially impact health outcomes.

References Beckham, N. (2007). Motivational interviewing with hazardous drinkers. Journal of the American Academy of Nurse Practitioners, 19, 103–110. doi:10.1111/j.1745–7599.2006.00200.x Handmaker, N. S., Hester, R. K., & Delaney, H. D. (1999). Videotaped training in alcohol counseling for obstetric care practitioners: A randomized controlled trial. Obstetrics & Gynecology, 93, 213–218. Lange, N., & Tigges, B. B. (2005). Influence positive chance with motivational interviewing. The Nurse Practitioner, 30, 44–53. Levensky, E. R., Forcehimes, A., O’Donohue, W. T., & Beitz, K. (2007). Motivational interviewing: An evidence-based approach to counseling helps patients follow treatment recommendations. American Journal of Nursing, 107, 50–59. doi:10.1097/01.NAJ.0000292202.06571.24 Miller, W. R. (1983). Motivational interviewing with problem drinkers. Behavioral Psychotherapy, 11, 147–172. doi:10.1017/S0141347300006583 Miller, W. R., & Rollnick, S. (2002). Motivational interviewing: Preparing people for change (2nd ed.). New York: Guilford. Murray, D. A. (2002). Motivational interviewing: Efficacy in substance abuse treatment and implications for therapist training and supervision. Unpublished doctoral dissertation, University of St. Thomas, St. Paul, Minnesota. National Organization of Nurse Practitioner Faculties (NONPF). (2011). Nurse practitioner core competencies (pp. 1–6). Retrieved from http://www.nonpf. com/associations/10789/files/IntegratedNPCoreCompsFINALApril2011. pdf

Teaching motivational interviewing

Perry, C. K., & Bennett, J. A. (2006). Heart disease prevention in women: Promoting exercise. Journal of the American Academy of Nurse Practitioners, 18, 568–573. doi:10.1111/j.1745–7599.2006.00182.x Rash, E. M. (2008a). Clinicians’ perspectives on motivational interviewingbased brief interventions in college health. Journal of American College Health, 57, 379–380. Rash, E. M. (2008b). Simulating health promotion in an online environment. Journal of Nursing Education, 47, 515–517. Rollnick, S., Miller, W. R., & Butler, C. C. (2008). Motivational interviewing in health care: Helping patients change behavior. New York: Guilford. Rubak, S., Sandboek, A., Lauritzen, T., & Christensen, B. (2005). Motivational interviewing: A systematic review and meta-analysis. British Journal of General Practice, 55, 305–312. Russell, C. L., Cronk, N. J., Herron, M., Knowles, N., Matteson, M. L., Peace, L., Ponferrada, L. (2011). Motivational interviewing in dialysis adherence study (MIDAS). Nephrology Nursing Journal, 38, 229–236. Sargeant, J., Valli, M., Ferrier, S., & Macleod, H. (2008). Lifestyle counseling in primary care: Opportunities and challenges for changing practice. Medical Teacher, 30, 185–191. U. S. Health and Human Services. (2020). Healthy People 2020 (pp. 1–4). Retrieved from http://www.healthypeople.gov/2020/topicsobjectives2020/ pdfs/hp2020 brochure.pdf Van Nes, M., & Sawatzky, J. V. (2010). Improving cardiovascular health with motivational interviewing: A nurse practitioner perspective. Journal of the American Academy of Nurse Practitioners, 12, 654–660. Whittemore, R., Melkus, G., Wagner, J., Dziura, J., Northrup, V., & Grey, M. (2009). Translating the diabetes prevention program to primary care: A pilot study. Nursing Research, 58, 2–11. doi:10.1097/NNR. 0b013e31818fcef

135

Teaching motivational interviewing to nurse practitioner students: a pilot study.

This quasi-experimental study examined the outcomes of a brief educational module for graduate nursing students as to using motivational interviewing ...
102KB Sizes 0 Downloads 0 Views