Meeting the Standard: Assessing Motivational Interviewing Among Primary Care Nurses

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July 31, 2015 by Nicholas Spence

checklistDaily, I come across a new study or clinician claiming the use of motivational interviewing. The question that always comes to mind is how well motivational interviewing is being used. This issue has received some attention in previous posts, but I came across a small study in BMC Family Practice, by  Ostlund et al., entitled “Primary care nurses’ performance in motivational interviewing: a quantitative descriptive study,” worth noting.

This study sought to examine primary care nurses’ motivational interviewing skills using the Motivational Interviewing Treatment Integrity (MITI) Code 3.1.1 and document self-rated assessments of their own motivational interviewing performance.

The MITI is composed of a global score and behavior counts in its assessment. The former assessment requires a rater to evaluate the interviewer using a five point scale based on an overall judgement of five main global dimensions of motivational interviewing, including collaboration, empathy, autonomy/support, direction, and evocation. In terms of the latter assessment, the rater simply indicates the number of instances of certain interviewer behaviors, such as giving information and use of closed questions, open questions, simple reflections, and complex reflections.

For this study, twelve primary care nurses who had used motivational interviewing (average of 5.6 years) were recruited from centers in two county council districts in central Sweden. They audio recorded 2-3 motivational interviewing sessions with patients lasting at least 10 minutes. The sessions focused on change in a patient’s lifestyle behavior, ranging from smoking to weight loss, diet and exercise habits to establishing sleep routines to seeking help for depression.

The findings were not encouraging. Most importantly, the ratings by two professional coders revealed that none of the nurses in the study achieved minimum proficiency/competency in motivational interviewing as set out by the MITI thresholds on every variable/summary score, based on global dimensions & behavior counts, for any single motivational interviewing session. Moreover, the participants greatly overestimated their own performance on the global dimensions of the motivational interviewing assessment. That being said, nurses with the highest scores had the most accurate self-ratings and those with the lowest scores had the least accurate self-ratings. In other words, the better one is at motivational interviewing, the more accurate one is at self-rating performance. With respect to behavior counts, nurses with lower scores had the most variation across behavior categories within their sessions unlike those with higher scores. The participants were most likely to overestimate their use of open questions. Far from surprising, the more training and/or feedback an individual had in motivational interviewing, the higher the clinical skill in practice as assessed by the MITI.

Although the study has several limitations as it was based on a non-random sample of just 12 primary care nurses who self-selected the sessions used for evaluation purposes, there is a central point to consider: the popularity of motivational interviewing across a variety of clinical settings for various lifestyle behaviors may only reach its full potential with adequate training, feedback and supervision.

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