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Motivational interviewing may be defined as “a collaborative, goal-oriented style of communication with particular attention to the language of change. It is designed to strengthen personal motivation for and commitment to a specific goal by eliciting and exploring the person’s own reasons for change within an atmosphere of acceptance and compassion” (Miller and Rollnick 2012). It is this students aim to demonstrate an understanding of this concept.
This will be achieved by critiquing a digital recording of a case scenario that this student previously recorded. Throughout this essay an understanding of the guiding principles used in motivational interviewing will be discussed along with interviewing skills. This student will critique herself on the use of the guiding principles and skills during the digital recording. Skills Motivational Interviewing (MI) involves certain techniques that help bring MI to life’ so to speak. These skills demonstrate the MI principles; they guide the process toward provoking patient change talk and commitment change.
Change talk in a patient is an indication for the nurse the patient is considering the possibility of change. There are different types of change talk which can be described using the acronym DARN. D- Desire (l want to change) A- ability (l can change) R- reason (the importance of change) and N-need (l should change). Another set of vital skills are used to bring about this ‘change talk. This time the acronym OARS is used. O- Open ended question; these questions are not easily answered by simply saying yes/nd. elp recognise patients strengths; this helps the patient feel that change is possible. R- Reflection; this is an important skill in MI; it links in the principle ‘listen with empathy. This skill is about listening carefully to give reflective responses. This helps the patient feel that s/he is being understood. S- Summarise; this allows the nurse and patient recap on the highlights of the conversation, it can see both sides of the patient’s ambivalence therefore both the patient and nurse can select what information should be included and what information can be minimised.
Throughout the digital recording I felt as though I severely lacked these skills however change talk id occur throughout the end with the patient stating “I know I should change”. Principles The principles of Motivational Interviewing (MI) were developed in 2002; expressing empathy, supporting self-efficacy, developing discrepancy and rolling with resistance (Miller and Rollnick, 2002). Recently new principles were established using the acronym RULE; R- resist the righting reflex, IJ- understand your clients motivation, L- listen to your client and E- empower your client (Rollnick 2008).
Resist the righting reflex: correcting a patient or giving them an alternative rather than providing uidance is often a common flaw among nurses. Resist the righting reflex refers to the inclination of wanting to fix the problem straight away and by doing so decreasing the likelihood of the patient themselves wanting to change (Rosengren, 2009). Throughout the digital recording I can see myself wanting to change the persons smoking habit asking her “have you ever thought about giving up… As it is seriously affecting your health. Instead I should have asked a more open question such as “How do you feel about cutting down on cigarettes? ” . As a nurse, we have the esire to help our patients change a situation so they become happier, healthier or perhaps lead a more productive life-style. The phrase “resist the righting reflex” refers to the need to resist the tendency to set our patients on the right track towards the goal we want to achieve with them. As humans we have a natural tendency to avoid persuasion (Rollnick and Miller 2002).
We can see this in the digital recording at the start, the minute I offer for her to go and see “someone”, she immediately backs up by saying “no, it’s not the right time”. According to Herman et al 2011, when we, as umans, hear reasons why we should change, our minds automatically contemplate reasons why we shouldn’t. In this situation the patient has other “issues” going on in her life at the present moment rather that quitting smoking. As a nurse I have to accept this. It was poorly portrayed in the digital recording in my opinion.
Resistance is the active process of pushing against reason for change (Herman et al 2011). This active process can be influenced by nurses either positively or negatively. Increased resistance may occur by convincing the patient they have a problem, arguing the enefits of change if the patient changes, by telling the patient how to change and by warning the patient of the consequences if they do not change (Moyers et al, 2007). In the digital recording, I can see myself using these negative influences, I warn the patient of serious health consequences caused by smoking, I also say that her “angina is linked with smoking”.
In future I will not take such a harsh approach and let the patient realise him/herself the situation with guidance from myself. I can see I interrupt the patient quite frequently which naturally enough puts strain on the he concept developed by Rollnick and Miller (2002); “rolling with resistance”. This principle avoids confronting the patient when resistance occurs. Any proclamations or action that may demonstrate resistance remain unchallenged. This in turn helps the patient to define their own problem and therefore can develop a unique solution which leaves little time to resist.
In other words, the nurse through guidance and support avoids the ‘righting reflex’, he/she lets the patient express their problem and concern and with guidance, construct a solution while making sure the patient nderstands the motives for change. Towards the end of the digital recording we can hear ‘change talk, the patient states “l know smoking is bad”, I feel I did guide the patient better towards the end eventually getting a deeper insight to her situation and felt a sense of achievement.
Understand your patient motivations: In order for the patient to want to change for his/her own benefit, the motivational interviewer must understand the patients motivations. The purpose of MI is that motivation must come from within the patient (Rollinick et al 2008). In other words as nurses we hould not motivate our patients; we help them to seek their own unique motivation factor as the patient’s own reasons for change are most likely to trigger change (Miller and Rollinick, 2002). As nurses, we help the patient recognise where they are and where they want to be.
It is important for the patient themselves to recognise the discrepancies that already exist and how their behaviour impacts their goal. Miller and Rollinick (2002) describe how a patient may very well want to stop something i. e. their level of alcohol consumption or the amount of cigarettes smoked per day, owever they want to and they don’t want to. We can see an example of this in the recording the patient states “l want to give up but I don’t want to…… this isn’t the right time”. This ambivalence is part of human nature. Patients are naturally ambivalent.
It is seen as normal as it is a natural process of change (Tobutt 2011). Rollinick et al, 2008 states that “When a person seems unmotivated to change or take the sound advice of practitioners, it is often assumed that there is something the matter with the patient and that there is not much one can do about it. These assumptions are usually false. No person is completely unmotivated”. This is seen throughout the digital recording, you can see how ambivalent the patient is. She wants to cut down her smoking habit but it’s not the right time.
The patient is seen to lack motivation. However I have used the skill of open questioning to get the patient to express the reason behind this. Through active listening I was able to identify a problem that may be an obstacle in the path to achieve the goal we wanted. At the end the patient identified her own goal, she found motivation from within. Listen with empathy: this principle contains two vital words associated with MI. Listen and empathy. According to Rosengren (2009), listening may be obvious however putting this into practice may prove otherwise.
Throughout the digital recording I did look as if I was listening attentively, however I do remember how difficult the skill active listening was. I had to be aware of my body language at all times. Although I have my arms crossed throughout the recording, my body stance was not uninviting in my opinion. Eye contact was also important. I feel I achieved this during the ecording without being too empowering. Patients come to us nurses for advice and expressing their feelings must be created. We can create this by being empathetic.
In the digital recording it is obvious the patient wanted to talk to myself not some other professional. I did not recognise this at first as I keep saying “do you want to speak to someone (councillor) about this? ” I should have realised this and appreciated the fact that I was the one she wanted to speak to. I repeated this statement too many times; I feel if this was a real life patient/nurse situation, the patient would not open up to e. In future I will be more acutely aware of these situations.
To approach a situation with empathy provides an environment for the patient to be heard and understood. Miller and Rollinick (2002) described this type of approach as a “fundamental and defining characteristic”. Empathy involves seeing the world through the patient’s eyes. If the patient feels understood they open up more and let the nurse or listener in on their deeper thoughts and feelings (McCabe 2004). Rosengren (2009) believes clinicians express this vital principle by using the skill ‘reflective listening.
I feel as if I did not give enough empathy to the patient at the start I did not giving her enough time to speak as I often interrupted. However the patient did open up in the end expressing her deeper feelings to me so perhaps she did feel at ease telling me about her situation. In my opinion I relaxed more as the digital recording went on, this influenced the patient and the conversation flowed more as a result. Conclusion In conclusion this student has learned a lot about motivational interviewing and how important it is to put these principles into nursing practice.
MI is imperative to ursing practice, as it involves patient desires, thoughts and feelings as a way to encourage the patients themselves to express their own barriers to change and to explore and resolve ambivalence to behavioural change. This student will take a lot of valuable lessons away with her after completing this assignment. In future this student feels she will have less frustration with those who aren’t planning to change and more patience with those who are contemplating change but are still full of ambivalence. This student has learned how important the skills are in relation to the principles.
In order to follow the guiding principles, skills should be followed to achieve the best possible outcome in patient centred care. Herman KC, Reinke WM and Sprick R. (2011). Motivational interviewing for effecrive classroom management; The classroom checkup. The Guilford press. McCabe C. (2004) Nurse-patient communication: an exploration of patients’ experiences. Journal of Clinical Nursing. 13, 41-49. Miller W. & Rollnick S. (2002) Motivational Interviewing. 2nd edn. The Guilford Press, New York. Miller W & Rollnick S. (2012). Motivational interviewing: Helping people change.
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