Improving patient safety through behavioral change is something that all healthcare providers strive to achieve. Supported by a three year grant, we are involved in a new way of doing this by using motivational interviewing (MI) among staff to improve patient outcomes.

A technique typically used by clinicians for patients, MI aims to empower and guide individuals towards health behavior change. Research studies have shown that MI achieves superior results compared to traditional patient education interventions for health behaviors including tobacco use, physical inactivity, and weight gain/obesity.

But ambivalent behavioral patterns are not limited to patients. Rather, indifference or resistance of staff to accept evidence-based changes is well known to explain why institutional quality improvement efforts fail in some settings.² Perhaps the most notorious example is that of hand hygiene, a key factor in preventing hospital infection. Despite international efforts to improve hand hygiene rates, clinicians simply do not wash their hands reliably enough to ensure safety. One multi-center study found that even after 12 months of audit and feedback to frontline staff, hand hygiene compliance remained 37% for intensive care units (ICUs) and 51% for non-ICUs.³

Sadly, there are countless examples of resistance to quality improvement programs aimed at preventing pressure ulcers, C. difficile infection, and reigning in antibiotic overuse. Despite substantial effort, too many physicians and nurses maintain old habits, and far too many patients continue to be harmed. Given the potential of MI to improve patient choices, we propose hospitals consider using MI with their personnel.

The MI process is collaborative as well as strategic, since most people do not respond well to direct persuasion. It is based on the premise that people are more likely to invest in behavioral change if they believe the change is their own idea. Practitioners of MI thus seek to first understand clients’ values—and then highlight the ways in which current behaviors are not aligned with those values. The goal is to guide clients to recognize and resolve ambivalence in the direction of behavioral change.

The MI practitioner employs two important techniques. First, they ask open-ended questions to elicit clients’ reports about current behaviors and thoughts and feelings about changing/not changing. For example, “How does the new hand hygiene policy affect your work?” Second, the practitioner listens carefully to the clients’ responses so as to describe the client’s internal experience without judgment or the practitioner’s viewpoint, “I hear you say that after all your years of work, you know how to protect patients without constantly washing your hands.” Such reflections aim to move the discussion in the direction of change, emphasizing more statements about desire or intention to change (which MI calls “change talk”), and less “sustain talk”—or statements about barriers or remaining the same.

Next the MI practitioner asks permission to bring in new information. For example, “Did you know that the hospital’s infection rate has spiked in the last year? May I share with you how some of the hospital’s other nurses have resolved this issue?”

The approach is not far-fetched: one innovative group has tested MI to improve hand hygiene among nursing personnel with promising preliminary results.⁴ Larger studies that also include diverse clinicians and physicians are necessary to further this work.

But even if studies validate the use of MI in changing clinician behavior, some barriers may make large-scale deployment challenging. For instance, having the necessary expertise to train practitioners and validate such training by evaluating MI skills in clinical settings will not be easy. Similarly, reinforcement of training and follow-up will require staff willingness to participate in the middle of busy work shifts. Furthermore, careful evaluation to define proximal outcomes (such as staff engagement or satisfaction with specific policies) and link these to behavior change or hand hygiene compliance rates are needed. Finally, studies that compare MI to other approaches (e.g. audit-feedback process, passive education, or financial incentives) aimed at improving hand hygiene are necessary. If successful, medical and nursing schools will also need to identify the best methods to teach this technique to new clinicians as they graduate every year.

While these are formidable challenges, the fact remains that quality improvement initiatives and education efforts have fallen short of goals. MI may be an important strategy to enhance healthcare worker compliance and, in turn, patient outcomes.

Sanjay Saint, MD, MPH^1,2, Lindsey Bloor, PhD^1,3, Vineet Chopra, MD, MSc^1,2

¹ VA Ann Arbor Healthcare System, Ann Arbor, MI; ² Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI ³ Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI.

Conflict of Interest: None declared for all coauthors.

The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.

Funding: Supported by a Program Project Grant from the Agency for Healthcare Research and Quality (1-P30-HS024385-01). The funding source played no role in study design, data acquisition, analysis or decision to report these data. This work was also supported by the VA National Center for Patient Safety through a Patient Safety Center of Inquiry Grant. Dr. Chopra is supported by a career development award from the Agency for Healthcare Research and Quality (1-K08-HS022835-01).

References

1. Lundahl B, Moleni T, Burke BL, et al. Motivational interviewing in medical care settings: a systematic review and meta-analysis of randomized controlled trials. Patient education and counseling 2013;93(2):157-68.
2. Saint S, Kowalski CP, Banaszak-Holl J, et al. How active resisters and organizational constipators affect health care-acquired infection prevention efforts. Joint Commission journal on quality and patient safety / Joint Commission Resources 2009;35(5):239-46. [published Online First: 2009/06/02]
3. McGuckin M, Waterman R, Govednik J. Hand hygiene compliance rates in the United States–a one-year multicenter collaboration using product/volume usage measurement and feedback. American journal of medical quality : the official journal of the American College of Medical Quality 2009;24(3):205-13. doi: 10.1177/1062860609332369 [published Online First: 2009/04/01]
4. Salamati P, Poursharifi H, Rahbarimanesh Aa, et al. Effectiveness of motivational interviewing in promoting hand hygiene of nursing personnel. International Journal of Preventive Medicine 2013;4(4):441-47.