EXCELLENT COMMUNICATION is key, no matter where nursing care is provided. From the ICU to the OR to an inpatient mental health unit, nurses must be flexible communicators to promote positive change in their patients.
The primary tool used in mental health nursing is therapeutic communication. Just as medical technology is constantly improving, so is the way that we communicate to promote the best outcomes for our patients. Research indicates that motivational interviewing (MI) is an effective communication style when used to encourage behavior change.1
In this article, we present a project that explored the effect of MI techniques applied by staff to engage patients in recovery in an adult inpatient mental health unit. Our desired outcomes were increased patient attendance at two cognitive behavioral therapy groups and improved quiz scores measuring staff knowledge of MI techniques. After the nursing staff on our unit were taught basic MI skills and encouraged to use the techniques when communicating with patients, both outcome measures improved significantly. Learning MI techniques enabled staff to use an evidence-based communication style to encourage patients to engage in recovery. This article presents the steps taken to achieve our project goals.
Setting the scene
Historically, the relationship between the mental healthcare professional and the patient has been one of unequal power, which included the professional giving unsolicited advice.2 Today the “doctor [or nurse] knows best” philosophy is outdated, and a collaborative relationship between the patient and healthcare team is recognized as the best practice for promoting recovery.3,4
This project took place at a 149-bed mental health hospital in California, on East Wing II (EWII), a 32-bed unlocked inpatient unit for adults with mood disorders, thought disorders, and chemical dependency. Cognitive behavioral therapy groups are offered on EWII each day to empower patients to identify, address, and manage thoughts and behaviors that affect their mental health. Patient participation in these groups is crucial to improve mental health outcomes.1
This quality improvement project began when nursing staff expressed dissatisfaction with a perceived inability to engage patients in recovery. Specifically, staff members felt unable to persuade patients to participate in cognitive behavioral therapy groups.
Patients must be empowered to engage in decision-making as part of the recovery process. This long overdue shift in the way that we communicate poses implementation challenges for both the nursing staff and patients. The desire of the EWII unit staff to learn skills to encourage patient engagement in recovery prompted the formulation of an action plan, starting with a literature review.
Review of literature
MI is a patient-centered, evidence-based method of facilitating change to promote patient autonomy and improve treatment concordance, satisfaction, and clinical outcomes.1 Important components of MI include expressing empathy and encouraging patients to identify discrepancies between their current behaviors and long-term goals.5
Resistance is to be expected when patients need to change their maladaptive behaviors.1 MI's philosophy is to accept and “roll with” resistance rather than to argue with the patient, which doesn't promote positive change.6
MI isn't just for psychiatric nurses; it's been effective in promoting lifestyle changes such as weight reduction and smoking cessation.1 MI has also been effective in encouraging patients to adhere to complex medical treatments such as heart failure self-management.1
MI is effective in brief interventions, with as few as two sessions needed to sustain positive outcomes for 2 years or more.7 Patients are usually on our unit for less than 1 week, so using a tool that can be used briefly to promote and sustain optimal outcomes was important.
A study by Dray and colleagues indicates patient satisfaction increases when staff members use MI techniques.8 This study determined that after staff members were trained in MI, patients reported feeling better able to approach and communicate with the healthcare team.8
MI is a cost-effective method of empowering patients to change problem behaviors.4 Train the trainer and self-study are two of the least costly training methods.9 Staff training costs are only a minor component of total treatment costs, and only three to four staff feedback or coaching sessions are needed to sustain skills.8-10
During a brief morning huddle with the unit clinical lead, EWII day-shift staff members discussed their frustration with limited patient participation in group therapy. The discussion evolved over several days, and concluded with EWII staff members requesting training in MI techniques to ensure supportive, change-oriented conversations with patients.
Data collection began to determine baseline patient group attendance and staff knowledge of MI techniques. On average, only 42% of patients were attending cognitive therapy groups during the preceding 2 months. This confirmed the staff's suspicion that many patients weren't attending groups.
An EWII staff member developed the baseline quiz to measure staff knowledge of MI techniques. The seven-question multiple-choice quiz was derived from two systematic literature reviews on MI training.11,12 The average baseline score was 74%. The quiz results demonstrated that some staff members were inclined to make unwanted suggestions to patients; other responses revealed the belief that patients can't be helped until they decide they want help.
Before MI education, staff members typically communicated with patients in a therapeutic manner. However, some staff members attempted to engage patients in a paternalistic way that could be interpreted as condescending. This communication style isn't in line with MI principles and can be counterproductive when the goal is to facilitate change.2 A formal structured educational approach was indicated to define expectations and ensure competence among staff.
This project used the OARS framework to teach MI. Conversations using the OARS technique incorporate open-ended questions, affirmations, reflective listening, and summarization.2 The aim is to engage the patient to work through ambivalence about negative behaviors or lifestyle changes.13
Staff members were asked how they would like to receive MI training to facilitate ownership of the project. The unit practice council adopted the project as a goal for the year and provided feedback about the educational design. Based on staff input and preferences, several teaching strategies were used, including train-the-trainer, an MI educational packet, one-on-one discussion, and a video.14
The day-shift clinical lead educated the evening- and night-shift clinical leads and advanced clinicians, who then educated their nursing staff on their shift. Each month, different MI techniques were discussed and then role-played in shift report and daily huddle. Corresponding educational posters were displayed on the unit.
The education implementation phase of this project was somewhat time-consuming and labor-intensive. In part, this was because staff education preferences were honored, but the one-to-one education ensured time for questions, discussion, and clarification as well as role-playing when necessary.
After receiving the MI training, staff members' average test score improved from 74% to 89%. The nursing staff used increased knowledge of MI techniques to communicate therapeutically with patients to engage them in their recovery. Staff members used OARS techniques when interacting with patients during shift assessments and throughout the day. The clinical leads and advanced clinicians observed staff members and provided feedback to assure alliance with MI principles. After staff incorporated MI into assessments with the patients, patient group attendance improved by 83%. (See Group attendance.)
During informal interviews, staff members reported satisfaction with the noticeable increase in patient group attendance. Staff also reported they noticed a culture shift, resulting in a changed relationship with patients, from one of unequal power to one promoting patient autonomy. This partnership with patients promoted engagement in recovery. Instead of the nurse communicating, “If you want to get better, then go to group,” the nurse initiated a conversation about the patient's ambivalence to change. This conversation promoted a therapeutic alliance leading to patient empowerment to participate in his or her recovery by attending groups.
Staff members were encouraged to identify how they'd like to receive training on MI techniques. Because staff members were involved in decision making, they felt ownership of the project, which increased participation. The various MI training techniques, while time consuming, enabled staff members to ask questions about the training and have one-on-one support. The effectiveness of the training was apparent in improved scores on the MI knowledge quiz.
As observed by clinical leads and advanced clinicians, staff members used MI techniques consistently when communicating with patients to express empathy and to encourage identification of discrepancies between problem behavior and values. Staff knew to expect patients to resist change and to accept this resistance to support patient autonomy.
Communication using MI techniques led to increased group attendance. The results of this project align with current research about the effectiveness of MI to facilitate positive change and treatment concordance by enhancing patient motivation.4
Our quality improvement project provides an example of successful collaboration between the formal and informal leadership team on EWII and the psychology department. Many times, when the frontline staff identifies a problem, management steps in to solve it. The situation described in this article illustrates what can be accomplished when staff, management, and a key ancillary department engage in true collaboration and teamwork.
Based on the results of this project, we conclude that educating staff on MI techniques can increase patients' participation in their recovery, and our recommendation is to train all staff throughout the hospital. As part of the hospital journey toward achievement of Magnet® designation, MI will be strongly emphasized in the future and facility-wide training is planned.
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