Summary on the article: Motivational interviewing within the different stages of change van Noordman et. al. (2013). An analysis of practice nurse-patient consultations aimed at promoting a healthier lifestyle

Research has found that primary health care may have a positive influence on the prevention and management of a patient’s lifestyle behaviour. A practice nurse is the one who can address a patient’s lifestyle and the one who can suggest certain lifestyle programmes. According to research, the practice nurses are the people, who look after the patients with severe conditions, give them lifestyle advice and help them during their battle against cigarettes and weight. Most primary nurses try to help people change by telling them the benefits of change in their lifestyle. However, according to some studies, the effectiveness of this method is ambiguous. By just telling people about the benefits of changing one’s lifestyle may not help changing complex behaviours like smoking, eating habits, physical activity and alcohol use.

If you really want to change health behaviour, then the patients as well as the practice nurse need to show effort, motivation and time. Patients usually vary in motivation during the course of their lifestyle change. Sometimes they may be very motivated to change, but a week later their motivation might be less. According to research , motivation interviewing might help change one’s lifestyle. With motivational interviewing, the care provider wants to enhance the intrinsic motivation and he or she does that by resolving the ambivalence between the desired behaviour and the actual behaviour. Patients vary in their level of motivation over time, so the writers of this text think that motivational interviewing needs to be combined with the Stages of Change construct. This combination may help the patients change their behaviour. Patients are not always as motivated as they used to be. According to the Stages of Change construct, patients have different stages of motivational readiness to engage in health behaviours. Because of this, the Stages of Change construct suggests that intervention methods need to be linked to the current stage of motivational readiness of a patient. The Stages of Change construct distinguishes five different stages of one’s predisposition to change:

1. Precontemplation: A patient has no intention to change behaviour within the next six months.

2. Contemplation: A patient does have the intention to change behaviour within the next six months, but he or she does not act on the interventions to change behaviour.

3. Preparation: The patient has the intention to change behaviour within thirty days.

4. Action: In this stage are the people who changed from unhealthy to healthy behaviour within the past six months.

5. Maintenance: This is the stage in which people are in who maintained the behaviour change for more than six months.

Patients may move forward as well as backward between these stages. Each specific stage of change differs in the stimuli and barriers people experience in the process of health behaviour change. Each specific stage of change has its own processes and factors which facilitate of hinder behaviour change. Researchers assume that patients will benefit the most if health care providers adapt their communication to the stage of change the patient is in. Still, there is some disagreement about the effectiveness of the Stages of Change. Some researchers think that the Stages of Change construct does not help to change patients’ behaviour. Researchers do acknowledge that communication should be adapted to individuals (whether it’s stage of change of not). However, it is still unknown whether practice nurses adapt their motivational interviewing or communication strategies to a certain stage during their real-life interactions with their patients.

The current study wants to explore if and to what extent practice nurses apply motivational interviewing techniques and communication skills during the different stages of change for patients. The targeted behaviour change is about dietary habits, alcohol use, smoking and physical activity. The writers of the article hypothesized that practice nurses would be more likely to invite and encourage patients to talk about behaviour change during the precontemplation and contemplation stage than during the other stages. This is also true for during the preparation stage than during the action and maintenance stage. This can be seen as consciousness raising. In theory, patients in the precontemplation stage would benefit the most from consciousness raising. They also suggest that practice nurses will ask more questions that let the patient tell them how he or she thinks and feels about behaviour change during the precontemplation stage and contemplation stage than the other stages. This looks like the principle of dramatic relief. In theory, patients in the precontemplation stage benefit the most from dramatic relief.

The writers also suggest that the practice nurses will are more likely to acknowledge challenges about the behaviour change a patients faces during the preparation stage, the action stage or maintenance stage than during the precontemplation or contemplation stage. This obviously, because in the preparation, action and maintenance stage the patient is ready to change or is already changing. The writers also hypothesized that patients and practice nurses were more likely to exchange ideas about how the patient could change in the preparation stage than in other stages. This is because patients show willingness to change in the preparation stage. Lastly, the writers suggested that the competence of the practice nurses will be independent of the Stages of Change construct.

Method

Nineteen practice nurses participated in this study and they all agreed to have ten consecutive, routine consultations videotaped. The practice nurses had on average 4,5 years of working experience. All the practice nurses were trained in motivational interviewing at one point during their education and thirteen of the practice nurses had extra post-education training in motivational interviewing. The consultations were videotaped.

Patients who participated in the research were asked to fill in a questionnaire about their sociodemographic characteristics (gender), their lifestyle behaviour (smoking, physical activity) and the reason for their consultation. The practice nurses filled in a short questionnaire after each consultation. The questions were about patient’s characteristics (age, gender) and perceived disease and complaints.

Patients who indicated in their questionnaire that they smoked or who reported to have a medium intensity physical activity level of less than thirty minutes a day, five days in the week were selected. The second selection criterion was that the lifestyle behaviour (alcohol use, dietary restraint, smoking and physical activity) of the patients was discussed during the consultation that was videotaped. Certain guidelines were used to observe and code the video-recorded consultations. The MAAS-global was used to rate the practice nurses’ clinical competence and communication skills. The application of motivational interviewing during each consultation was coded using the BECCI-checklist. Also, the patients’ stages of change were observed. When a patient had multiple unhealthy behaviours during one consultation, the behaviour for which the Stages of Change became most evident during the consultation was selected. Statistical analysis was used on the data.

Results

According to the data, there was only one significant difference between the patience SOC’s: there were more patients in the (pre)contemplation or preparation phase for smoking behaviour. The data also showed that practice nurses summarized less during their conversations with patients who are in the action or maintenance stage than with patients in the other stages. Practice nurses also tend to pay more attention to ‘request for help’ and ‘management’ with patients in the preparation stage than with patients in other stages. They also show more empathy during the conversations with patients in the action or maintenance stage. It seems that practice nurses adjust their motivation interviewing to patients’ Stages of Change, but only to some extent. As mentioned above, practice nurses summarized less during their conversations with patients who are in the action or maintenance stage than with patients in the other stages. There were also trends found for ‘request for help’, ‘management’ and ‘empathy’. The hypotheses were partly confirmed. As predicted, practice nurses did encourage patients to talk about behaviour change more in the contemplation and precontemplation stage than during other stages. They did this also more during the preparation stage than during the maintenance and action stage.

However, one of the hypotheses was not entirely correct. It turned out that practice nurses invited that patient to talk about behaviour change in the preparation stage more than during the contemplation and precontemplation stage. The other hypotheses could not be confirmed. Practice nurses, it seems, apply their motivation interviewing skills on average more when patients are in the preparation stage than in the other stages. Practice nurses’ clinical competence did not vary by Stage of Change group. The writers of this article suggest that practice nurses need to be taught to explicitly identify a patient’s Stage of Change in order for the to enhance their adaptation of motivation interviewing.

There are some limitations of this study. The first one is that both observation protocols (the BECCI and the MAAS-global) focus on communication skills of healthcare providers and they do not include patients’ statements. The second one is that the writers used MAAS-global for coding nurses’ communication skills. However, this instrument was originally developed for physicians. Another limitation is a limitation to the discussion. The researchers only chose patients who smoked or did not adhere to the Dutch physical activity norm and thus the discussion of smoking and/or physical activity in other consultations between patient and nurse could be underestimated.