Motivational Interviewing in Pediatric Nursing

Journal of Pediatric Nursing (2016) xx, xxx–xxx
Learning Motivational Interviewing: A Pathway to
Caring and Mindful Patient Encounters
Diane Kennedy RN, PhD ⁎, Timothy Apodaca PhD, Kelly Trowbridge PhD, LCSW, LSCSW,
Carol Hafeman RN, BSN, MA, Edith Roderick RN, MSN, APRN, BC, PNP,
Ann Modrcin MD, EMBA
Children’s Mercy, Kansas City, MO
Received 26 February 2015; revised 15 December 2015; accepted 18 December 2015
Key words:
motivational interviewing;
communication;
professional development
We designed our project to explore the experience of learning motivational interviewing (MI). The
project impetus came from a desire to improve our skill in communicating with patients. We created a
curriculum led by an MI specialist that provided didactic sessions, discussions and individual feedback.
In evaluating our audio-taped MI encounters, we approached beginner proficiency. Also, we recognized
the need for formal MI education and practice to fully develop the interventionist skills needed for
clinical work and our next research project about preparing patients for transition to adult health care.
Lastly, we realized that MI strategies reflect aspects of caring theory and mindfulness, important
components of patient-centered care.
© 2015 Elsevier Inc. All rights reserved.
AS CLINICIANS WHO provide pediatric rehabilitation
services, we are passionate about promoting healthy
lifestyles and recognize that communication skill is important in motivating patients. Our multidisciplinary team works
hard to involve patients in planning care, sometimes with
success and sometimes not. Motivational interviewing (MI)
is a well developed counseling approach that is patientcentered and can inspire positive change (Rollnick, Miller, &
Butler, 2008). Clinicians who successfully use the dynamic
tools of MI convey genuine interest and gentle guidance. The
defining characteristics of MI include open-ended questions,
reflective listening, affirmation of patient strengths and
clinician summaries of the patient viewpoint. These
techniques give the patient a safe opportunity to explore
personal values, goals and possible solutions for improving
health. In adult and pediatric studies, there is evidence to
support the use of MI to manage chronic health conditions
(Jensen et al., 2011; Lundahl et al., 2013; Suarez & Mullins,
2008). As a team, we were intrigued and wanted to learn MI
⁎ Corresponding author: Diane Kennedy, RN, PhD.
E-mail address: [email protected].
http://dx.doi.org/10.1016/j.pedn.2015.12.011
0882-5963/© 2015 Elsevier Inc. All rights reserved.
to improve our care-giving abilities, and so, our professional
development project unfolded.
Project Aim
In our project, we aimed to develop our skills in the art of
motivational interviewing (MI). More specifically, we wanted to
learn MI and implement this communication strategy in our
Spinal Defects Clinic with children/adolescents/parents who
need to perform daily clean intermittent catheterizations (CIC).
These children, especially adolescents, are challenged with
following a daily routine of this nature (Edwards, Borzyskowski,
Cox, & Badcock, 2004).
Background and Significance
Interestingly, there is considerable empirical support for
using MI in pediatric conditions like diabetes, obesity and
addiction to bring about positive lifestyle changes that
include learning new health-related procedures (Erickson,
Gerstle, & Feldstein, 2005; Gayes & Steele, 2014; Jensen
et al., 2011, Suarez & Mullins, 2008). Of note, in a PubMed,
Ovid, CINAHL and PsycINFO search, we found no
intervention studies about using MI in the spina bifida
2
population. In another search (PubMed, CINAHL, Ovid)
about CIC and spina bifida, we found only descriptive
studies that report parental/family stress, individual complexities and patient stigma with managing incontinence
(Borzyskowski, Cox, Edwards, & Owen, 2004; Chick,
Hunter, & Moore, 2013, Edwards et al., 2004; Fagerskiold
& Mattsson, 2010; Fischer, Church, Lyons, & McPherson,
2015; Kanaheswari, Razak, Chandran, & Ong, 2011). We
need more studies about empowering patients in doing
intermittent catheterizations throughout the day as the
procedure is a significant lifestyle change.
Clean intermittent catheterization (CIC) should be done
every three to four hours, requires good handwashing and
clean catheters and involves gently inserting a lubricated
catheter into the bladder. When the bladder is emptied, the
catheter is removed. We know that when CIC becomes a
consistent practice, children with spina bifida can often
experience less incontinence, achieve social continence,
reduce odor and prevent renal dysfunction (Mourtzinos &
Stoffel, 2010). Many of these children reach adulthood and
lead fulfilling lives, especially when CIC is part of a daily
routine. Those who struggle with this routine are good
candidates for motivational interviewing as the conceptual
components of MI are concrete, intuitive and easily applied
in our conversations with patients about CIC.
Examples of MI Strategies
Motivational interviewing is a collaborative communication style in which the clinician separates from the traditional
authoritarian medical model and attempts to gently elicit
insight from the patient (Rollnick et al., 2008). First, one
must express empathy by listening reflectively, accepting
ambivalence and affirming strengths. The patient is viewed
as capable of change despite the expression of reluctance.
The clinician develops discrepancy, meaning the patient not
the provider presents the arguments for change. One must
listen for statements that reflect discrepancy and then
encourage the patient to develop a concrete plan. Also, the
clinician must roll with resistance and always obtains
permission to explore health issues. Patients will appreciate
a simple query. Can we talk about some of the pros and cons
with doing CIC? At the same time, providers must
emphasize the patient’s freedom in choosing. Lecturing
does not work with ambivalent patients. A kind, respectful
approach in exploring ambivalence can be a powerful trigger
for change. If patients have not been successful with CIC, the
experience could be reframed as positive. You have
experience with CIC so you know what works and doesn’t
work for you. Lastly, the clinician must support self-efficacy
by encouraging choice and conveying a belief that the patient
can change. I sense that you are a very determined person.
The following MI strategies with exemplars reflect our
project aim. OARS is the acronym for these strategies. Each
letter of this acronym is illustrated in the examples that
follow.
D. Kennedy et al.
Open-ended questions: How does cathing fit with your daily
routine?
Affirmations: I’m very impressed with how well you do the
procedure.
Reflective listening: It’s embarrassing to leave the classroom to
do cathing in the nurse’s office.
Summary statements: It’s important for you to be dry and stay
healthy. On the other hand, cathing would be a big change in
your life and may be hard to accomplish, especially four to five
times a day. What else would you add?
When clinicians respect patient autonomy, the provider/
patient relationship is a collaborative partnership, not
authoritarian and prescriptive. In “doing motivational
interviewing”, one develops a therapeutic connection that
can be an authentic expression of caring.
Project Design and Structure
Our project team included two RNs, a nurse practitioner,
social worker and physician. All team members were female
and mid or late career clinicians who work in a Midwestern
children’s hospital in the Rehabilitation Medicine Clinics,
which includes the Spinal Defects Clinic. We completed
formal MI instruction before inviting participation from
ambivalent subjects who were identified during Spinal
Defects Clinic by the urologist/APRN as appropriate for
CIC. We audio-taped five interviews with subjects from this
clinic to critique our MI skill. Our subjects are described in
Table 1. Also, we were encouraged by our MI trainer to
practice the MI strategies with patients or parents in other
settings. As part of the MI learning trajectory, we kept a
reflective journal about our MI encounters. The project was
an IRB approved plan for professional team development.
Our experience with learning MI began with a 4-hour
workshop held during our yearly Rehabilitation Medicine
Department retreat. One of our in-house child psychologists
who is an MI trainer and researcher introduced the MI
philosophy and strategies. The seminar content stimulated our
interest and soon after we planned more formal training.
Subsequently, our MI trainer led three, 3-hour, on-campus
sessions over a two month period. The training included
didactic instruction, discussion following MI videos, multiple
MI practice sessions with each other and discussion of
scenarios related to CIC. During the duration of this project,
we met weekly over the lunch hour to role-play, discuss
readings, view MI videos, set realistic goals for our next
meeting and identify interview candidates. Monthly, our MI
trainer met with us to review our audiotape-recorded role-play
and live interviews. We were able to easily incorporate our
meetings and training into our clinical work schedule.
Our MI trainer followed the MITI 3.1.1 interview coding
scheme developed by Moyers, Martin, Manuel, Miller, and
Ernst (2010). These researchers developed an explicit coding
methodology for rating clinician interview skill (intervention
fidelity): global spirit of MI and MI behavior counts
(open-ended questions, reflections, etc.). Overall, we were
Learning Motivational Interviewing
Table 1
3
Description of the Patient/Parent Participants (Interviewees).
Alias name and age when interviewed
Who does
cathing?
Reasons for change
Maya, 14 years old, female, ambulatory, desired wearing cloth undergarments,
Patient
To stay dry…
understands risks related to urine stasis, has fear of kidney failure, cathing was a
To be healthy…
hassle, cathing importance rated 10 but confidence rated 4, eager to develop a change
To avoid surgeries…
plan.
John, 11 years old, male, wheel-chair (w/c) user, very engaging and social, a lady’s Mother, sister,
Did not develop a plan
man from the womb who has a lot of potential (per mother), described cathing as school personnel, during interview
hard.
sometimes patient
Anna, 15 years old, female, ambulatory, a soft ball pitcher, cathing was weird at first, Patient
To not leak and stay dry…
desired wearing cloth undergarments, cathing importance rated 6, confidence rated 3
To stay healthy…
or 4, it hurts if you don’t do it enough but I don’t really get sick when I cath less.
To be in control of me…
Mary, (mother), 7 year old daughter, mother wanted to learn but fearful of hurting child Father
Needed to share CIC
though able to change tracheostomy tube, father is child’s school para and became a
responsibility with father
nurse after birth of child, cathing described as a lot to do, child is a w/c user.
Elsa, 16 years old, female, w/c user, reports of cathing not consistent with
Patient
Because not cathing
uro-dynamics, wanted summer job so needed a routine for work schedule.
may hurt my kidneys…
To feel better…
approaching beginner MI proficiency at project completion.
To achieve beginner proficiency as described in Table 2,
50% of questions should be open-ended questions, 40% of
reflections should be complex reflections and global
empathy should be rated a 5 on a 1–7 scale. Training was
an on-going process as we dissected each interview during
our monthly meetings with our MI mentor who provided
individual, detailed clinician feedback about ways to
improve our MI skills. Due to time constraints and limited
resources, we were unable to demonstrate coder intra-rater or
inter-rater reliability. A one page interview guide served as
our “safety net” during interviews (Table 3).
The Learning Curve
We have discussed our learning curve and insights as well
as recommendations for all health care providers who
encounter patient ambivalence regarding positive lifestyle
changes. To begin, we want to share excerpts from our MI
encounters with patients who are described in Table 1. We
have summarized a few interesting discussion points from
the interviews with John, Anna and Maya.
When John was asked what would need to change to start
cathing more often, John responded nothing. Open questions
of this nature may be too abstract for the more concrete
thinkers. More focused questions like who could help you do
your own cathing at school may work better. John’s mother
recognized his struggle and pointed out that he may not get
all the urine out, suggesting her own ambivalence though she
wanted him to be independent. The attention span of
younger children may be an issue, too. After about
10 minutes of talking about cathing at home and at school,
John assertively said I’m good and wanted to end the
interview to listen to music on his phone. Though a brief
interview, we deemed the encounter a good beginning that
provided the opportunity to involve the child.
When John made closure, his mother began to express her
angst. What if something happens to me and no one knows
how to take care of John. I need to make a file with all of his
health information……He can learn to take care of
himself……I’ve had to fight hard with the school to keep
the para who definitely can supervise John when he caths……
How do you find an employer who understands?……I need to
organize his supplies at home to make it easier. She took
pride in creating step-by-step instructions for cathing for a
college course. As we talked, she realized that posting these
guidelines in the bathroom at home would be helpful. When
given the opportunity to speak freely, John’s mother
presented legitimate concerns as well as a few solutions,
which is the goal of MI.
In the interview with Anna, several times, she communicated openly and honestly. I know I could if I really wanted
to but I don’t really want to……… It’s obvious you’re
different if you do it at set times. Shades of ambivalence were
apparent. Nonetheless, Anna agreed to work on a change
plan when given the choice. She wanted to cath more
frequently. But, it’ll be hard, but I’ll do it. I’ll try. I want to
do it, but it’s really hard sometimes. Interestingly, Anna,
who was a new patient to the clinic, recalled that no one has
explained why cathing is important and greatly appreciated
this information.
As we listened to the MI tapes with our coach, we
discussed the intervention experience, which was an
opportunity to brainstorm. If a patient agrees to work on a
change plan, clinicians should offer suggestions with
permission, of course. For example, keeping a reminder
like a picture of attractive undergarments that is hidden in a
notebook has helped some of our patients stay on track. The
experiences with Anna as well as Maya suggest that wearing
undergarments rather than incontinence briefs on return
visits to clinic may be an objective measure of MI success. A
4
D. Kennedy et al.
Table 2
Interventionist Scores (Adapted from MITI 3.1.1).
MI behaviors
Role play scores
Patient interview scores
Beginner proficiency
MI competency
Motivational interviewing behavior counts
% MI adherent
100 100
% Open questions
39
69
% Complex reflections
24
54
Reflection to question ratio 0.75 1:1
100
35
36
0.55
100
23
22
0.3
100
65
19
0.70
100
50
50
0.25
100
88
0
0.25
100
72
20
0.69
100
83
25
0.75
90%
50%
40%
1:1
100%
70%
50%
2:1
Global spirit of motivational interviewing
Global empathy (1–7)
4
6
Global MI spirit (1–7)
4
6
6
5
4
3
6
5
5
4
6
6
5
6
5
5
5
5
6
6
Theresa Moyer, one of the MITI authors, granted permission to use the MITI in this project.
cathing diary could be a subject burden as well as a risky
assessment of change.
The novice MI provider can expect to be nervous about
doing a live or practice audio-taped interview, but, we found
that with training and role-play practice, the beginner can
bring forth an honest dialogue with the patient. Of interest to
those who had long term relationships with our patients, the
clinician who was unfamiliar to the patient elicited
unexpected interest in cathing. A new provider may offer
an opportunity for a fresh start.
In analyzing our interviews, we recognized the need for more
interpretive or complex reflections. When Anna shared her
concern about everyone knowing, an interpretive response like I
can imagine you have concerns about being different could
create meaningful dialogue. Also, listening to tapes gave us
awareness of personal verbal “tics”, if you will, phrasing like
okay…okay…okay to buy time for collecting thoughts or tell
me about (authoritarian) rather than what is it like (MI adherent).
Table 3
Before each interview, we recommend taking a few minutes
to reflect about MI strategies: give choices, allow time to
process thoughts (silently count 1, 2, 3), ask questions that
begin with how or what and obtain permission. The provider is
the intervention and pre-interview review of MI strategies is
helpful. Likewise, when we reflected about our interviews in
our weekly meetings, we recognized missed opportunities that
could be addressed during the next clinic visit. In our Spinal
Defects Clinic, the provider team meets after clinic for
planning care. This is an ideal time to discuss and document
these details and identify patients who may benefit from MI
follow-up. A phone text or email conversation following a
clinic visit could give time for the patient to think about
possibilities and the provider the opportunity to strategize.
Aside from patient scenarios about ambivalence, we
realized that the OARS strategies are useful communication
tools in other aspects of care. What are your main concerns
for this phone visit (triage and history taking)? What have
Motivational Interviewing Guide for Use in Clinic.
Opening the interview
Building rapport
Building motivation
Exploring pros/cons
Looking forward/back
Exploring goals/values
Providing personalized feedback
Assessing motivation
Importance and confidence rulers
Recapitulation
Transitioning if appropriate
Key questions
Giving advice and information
Creating a change plan
Eliciting commitment
Setting goals
Considering change options
Arriving at a plan
If change plan not appropriate, “plant seeds” for change
Ending the session on a good note
I appreciate your willingness to talk…………
What is a typical day like for you………
What was hard about cathing? What might be good about cathing…?
When you think about your health, how have things been going…
What things are important to you right now……
You’ve shared a lot about yourself………
All right, what makes importance a 5 rather than a 0…
Let me try to summarize and please tell me if I’ve left anything out……
At this point, what might be next for you…
Would it be okay to tell you a few things that occur to me……
You’re sure things can’t stay the same. Where do you go from here…
What do you think is the first step…
What do you think might work best…
How might you achieve this goal…
You said earlier that you are at a 2 or 3 on the importance scale.
What might need to happen to move to an 8 or 9……
I appreciate your honesty……
Thank you for letting me get to know you a bit……
If you like, we can talk more during your next visit……
Learning Motivational Interviewing
you been told about your child’s diagnosis (patient
education)? How do you feel about what you’ve been told
about your child’s condition (palliative care)? I’d like to hear
about your decision to have spine surgery; what was that like
(qualitative research)? In our clinic, our medical director has
championed a process for transitioning our patients to adult health
care. When using MI to engage the ambivalent patient about
self-care and independence, we create a segue way to this topic.
Families often site breakdowns in communication as a major
stressor in the health care experience. Last year in our hospital,
eighty percent of family contacts with the Patient Advocate
Department were about staff communication and attitude
(Patient Advocate Department, personal communication, January 9, 2014). In an effort to reduce these stressors, we suggest
that educators across health care professions (nursing, medicine,
social work, etc.) introduce MI strategies early in training.
Students need role-playing opportunities and formal evaluation
analogous to checking-off on technical skills like placing a
catheter. Data suggest that MI competence cannot be accomplished without practice and feedback though the MI training
dose for achieving competency is uncertain (Bohman, Forsberg,
Ghaderi, & Rasmussen, 2013; Dunhill, Schmidt, & Klein,
2014). We agree that the benefits of interview coding and
listening to our interview tapes were significant. In planning a
study to test an intervention package that prepares young adults
for transition to adult health care, we want to include the MI
intervention and participate as MI interventionists, but, to ensure
intervention fidelity, we realize the importance of continued
practice and thoughtful self-evaluation.
Though a bit unexpectedly, we discovered that MI provides
the tools to operationalize theoretical components of caring and
mindful practice. The senior leadership from our pediatric
hospital has formally adopted a philosophy of care driven by the
Quality Caring Theory developed by Duffy (2009), a critical
care nurse. Duffy posits that through caring relationships
individuals live, learn, work, change and grow. Several of
Duffy’s caring constructs mirror the conceptual components of
motivational interviewing: mutual problem solving, human
respect, encouraging manner and appreciation of unique
meanings. The implicit essence of motivational interviewing is
easily captured through the lens of the Quality Caring Model. In
another effort to improve patient care, the behavioral clinicians
in our facility recently introduced a practice initiative grounded
in the power of mindfulness. Ryan and Deci (2008) make a case
for the use mindfulness in clinical practice as a way to support
patient autonomy. Historically, individuals with chronic
conditions experience paternalistic care (Areheart, 2008).
When practicing mindfulness, providers thoughtfully recognize
paternalistic biases and prescriptive tendencies. In “being
mindful” of personal beliefs, we can convey a non-judgmental
tone and better achieve the spirit of MI.
Summary of Clinical Implications
We agreed that learning MI is a worthwhile professional
investment that is relevant in a patient- centered practice
5
model. The MI strategies reflect the basic tenets of respectful
and therapeutic patient/clinician interactions and can become
standard practice. We found that formal and supervised
MI training across disciplines is feasible but acquiring the art
and skill of MI requires self-directed, mindful practice. In our
reflective discussions, we recognized that motivational
interviewing is a caring intervention that is an important
consideration for our future work in health care transition
science.
It’s about acceptance of imperfect patients who will
always have strengths that can be the starting point.
Plus, we are encouraging our patients to teach us……Sort
of a humbling experience. We think of ourselves as good
teachers but stepping back and hearing the patient’s
story is fascinating and our first priority……“How” and
“what” questions bring so much depth……What I like
about MI is how great it is when patients discover their
own answers……Expert feedback gives great insight into
the soft and subtle art of communication.
Our vision for our rehabilitation services is to inspire
patients with physical disabilities like spina bifida to live
extraordinary lives. We are optimistic that motivational
interviewing can create one of the pathways to this end.
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