View the full Ausmed lecture: Communication and Engaging with People with Addictions
Making changes to established habits can be challenging, and simply giving patients advice about the lifestyle choices needed to achieve a healthier life can often be met with resistance, inaction and residual ill health.
Without additional assistance, lifestyle prescriptions are often ignored. With this in mind, how can healthcare professionals help their patients to overcome resistance to change?
One answer comes from the developing field of motivational interviewing (MI).
Motivational interviewing is a well established patient-centred approach that supports behaviour changes (Britt 2004).
When first developed by Miller and Rollnick over two decades ago, MI was used mainly in the fields of addiction and substance misuse (Rollnick 2010). Today, however, its use has broadened to embrace a diverse range of clinical settings and patient groups.
Although primarily used in the field of health promotion, MI is now also having a significant impact on patients' self-management for some of the most serious diseases caused by lifestyle factors.
As Rollnick et al. (2010) suggest, by incorporating some basic conversational changes into consultations, it's possible to encourage behavioural changes by guiding patients to clarify their strengths and aspirations, evoke their own motivations for change, and promote autonomy of decision making.
Simply telling patients to change their behaviour is often unrewarding and ineffective.
Motivational interviewing, on the other hand, uses the basic communication skills of reflection, active listening and open-ended questioning to guide - rather than lead - the patient towards healthier outcomes.
Central to the success of MI is the ability to help patients clarify their strengths and aspirations, raise their desire and motivation to experience better health and strengthen their decision-making process. It's a consultation style that places the locus of control with the patient, assisting them to tap into their own inherent resources.
(RCN 2018)
To be successful, practitioners must be able to identify the patient's core values and goals and use these as a basis to encourage behavioural change.
Use of positive solution-focused language throughout the conversation is also key to gaining agreement to health-enhancing changes. This is reflected in the four basic principles of MI.
(RCN 2008)
Many healthcare professionals still trend towards a paternalistic style of conversation by 'telling' patients what they need to do.
In many cases, there is nothing wrong with this. It's how we inform, prescribe and teach, and for most patients, most of the time, it's a helpful approach to take. It assumes that the patient is willing and able to change.
However, when lifestyle changes are needed, that approach doesn't always work.
If a patient isn't sufficiently willing, able, focused or motivated to 'change' without additional help, then using techniques such as motivational interviewing can be a useful way of helping them to move past their own resistance and take action.
Simply shifting from direct suggestions and telling, to using indirect suggestions and asking, can help raise motivation and the desire for something better. It's a relatively easy way of helping someone who may be resistant to change to focus on their best potential and increase their willingness to take action.
There are many similarities between motivational interviewing and solution-focused therapy, as Stermensky et al. (2014) point out.
For example, embedding solution focused presuppositions into conversations about lifestyle changes is just one way nurses can help focus the patient's attention on achieving a positive result.
A presupposition is simply an assumption that can be used conversationally in order to help guide someone to fulfil an outcome.
Linguistically, the presupposition must be assumed to be true for the sentence to make sense, and so it becomes a fast and effective way of bypassing conscious resistance to an idea.
Nurses are ideally placed to embed solution-focused questions into conversations. It's an easy, cost-free intervention that has the potential to help patients recognise and overcome any obstacles in the way of change (RCN 2018).
For example:
Motivational interviewing has been shown to promote behavioural change in a wide range of healthcare settings (Rollnick 2010).
To date, research results have proved extremely promising as a precursor or complement to other interventions. A wide selection of high-quality research and training resources can also be accessed online (MINT 2017).
Although initial support for MI came from practitioners working in the field of addictions, it's now recognised as an intervention that can be adapted and applied to a range of problem behaviours, having a 'common currency' among health professionals (Ashton 2011).
Bunyan et al. (2017) suggest that learning the skills of motivational interviewing might be a useful way of helping nurses to improve their communication skills and think in detail about their interactions with patients.
This stands in some contrast to the views of Noordman et al. (2012), who suggest that motivational interviewing skills are not easily applicable in routine practice.
Yet, it could be argued that a middle solution also exists by taking techniques from the motivational interviewing approach and integrating these into routine patient consultations (RCN 2018).
As Scott (2010) points out, nurses could play a major role in improving health outcomes simply by incorporating motivational interviewing skills into therapeutic conversations, potentially addressing some of the productivity challenges of modern healthcare systems.
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