Motivational interviewing is a technique occupational health professionals can use to help them understand what may motivate a client to change unhealthy behaviours and, in turn, help them return to work. Professor Jane Wills and Professor Anne Harriss explain how it works and can make a difference.
Occupational health (OH) takes a proactive approach to health, considering the effect of work on health and just as importantly the impact of health on work.
The World Health Organization (2001) recognises OH as being a specialist branch of public health, and occupational health nurses (OHNs) are integral to promoting and supporting the health and wellbeing of workforces in a variety of settings.
The Council for Work and Health (2010) emphasises that OH practitioners should take every opportunity to promote employee health and this approach is integral to the Making Every Contact Count initiative of Public Health England and Health Education England (2016).
There is strong evidence that (good) work has health related benefits and being out of work can impact negatively on physical and mental health (Waddell and Burton 2006; Black 2008; Marmot 2010; National Institute for Health and Care Excellence 2015). The OHN has an important role in supporting people with health issues to make health related behaviour changes in order that they are able to stay in employment.
From a workplace perspective, and at a micro-level, poor health has the potential to impact negatively on both the quality of life of individuals and on their ability to undertake their job requirements. Front-line posts in the emergency services, for example, require specific levels of physical fitness, and dietary choices, lack of exercise and smoking behaviours are relevant to these fitness levels.
At a macro-level this may affect the organisation’s productivity and effectiveness (Palmer et al 2013). Multi-faceted workplace health and welfare promoting activities are integral to the role of the OHN, particularly so in their role in developing effective return to work strategies following periods of sickness absence and assisting those with physical and/or mental difficulties to remain economically active.
Attitudes to health, illness and work are key issues in the support of individuals in maintaining their wellbeing throughout their working lives. For some, there are significant challenges associated with a return to work following a prolonged period of absence, particularly if this is related to alcohol or substance misuse or the experience of workplace stressors such as bullying which impacts on their mental health. Individuals may indicate a lack of confidence in their coping mechanisms relating to an effective return to the workplace. Related to all of these are the individual’s readiness, willingness and ability to change aspects of their life.
Motivational interviewing (MI) is a style of client-centred counselling to facilitate health-related behaviours by resolving clients’ lack of motivation (Miller and Rollnick 2012). It was developed in the USA for counsellors working with addictions who found that trying to persuade problem drinkers to change their behaviour through direct persuasion or confrontation was unproductive and led to denial and resistance.
In MI the practitioner will use three principles – collaboration, evocation, and autonomy – in order to establish rapport and initiate a conversation, reduce resistance, develop discrepancy between what is happening now and what the individual values for the future and elicit “change talk” (the patient’s own reasons and arguments for change) (Hettema et al., 2005; Miller & Rollnick, 2012).
MI includes a number of simple communication techniques for assessing readiness to change and patients’ perceived self-confidence, for weighing up the pros and cons of current behaviours and exploring ambivalence and setting goals for self-management. Whilst these simple communication strategies can be taught, Miller and Rollnick (2012) refer to the “spirit” of MI, that it is as much about supporting patients’ sense of responsibility, empowerment, and self-confidence as it is about using techniques.
Although NICE guidance on behaviour change techniques does not specifically recommend motivational interviewing (National Institute for Health and Care Excellence 2014), Rubak’s (2005) meta-analysis found that MI outperforms traditional advice giving in the treatment of a broad range of behavioural problems and diseases. The approach has become widely adopted throughout health and social cares services and is used as part of brief interventions in clinical settings on many issues from smoking cessation to managing diabetes.
It has not been widely used in occupational settings, although Butterworth et al (2006) explored the effectiveness of health coaching using motivational interviewing techniques. They found that the offer of “health coaching” was attractive to the higher risk individuals who might not otherwise take up health promotion interventions in the workplace.
The Harrison report for the Council for Work and Health (Council for Work and Health 2014) whilst reporting on the rise of long term conditions and that workplaces are places where lifestyle factors that contribute to the future burden of public health can be addressed to keep people economically active, did not identify these skills in its examination of future training needs. Similarly, the skills of motivational interviewing are not integral to the Public Health England (2016) document Educating Occupational Health Nurses.
This article explores the relevance of an MI approach to OH practice from the perspective of experienced OHNs who are practice teachers (PTs) supporting the workplace based learning of students enrolled on the PG Dip/BSc (Hons) Occupational Health Nursing Specialist Community Public Health Nurse (Occupational Health) at London South Bank University.
A convenience sample of 15 PTs was offered a one-hour introduction to motivational interviewing. A focus group and short survey used semi-structured questions to explore current OH practice and whether MI was an approach that could be integrated into practice.
Findings and discussion
For four of the practice teachers, it was the first time they had heard of MI. All of the practice teachers felt that MI was relevant but they did not feel it reflected their current practice:
“We are more about information giving and persuasion to get someone fit for work.”
“At present OH is focused on readiness to return to work rather than promoting/reducing ill health.”
Several described OH practice as sitting within a medical model in which the practitioner identified health problems and then seeks to remedy them. It was described as “functional not holistic”.
Several of the practice teachers were aware that the approach of MI was contrary to their communication style:
“This might stop me thinking I had to change people”
“I’m a fixer”
Miller and Rollnick (2012) refer to this innate instinct to offer a solution to “right” the problem and as particularly evident in nurses. This righting reflex means nurses frequently impose their own perspective. For example, one PT referred to a client, Mr J who broke his leg on site nine months ago. He usually spends his day watching TV, and the nurse in the OH interview about his return to work explained the benefit of exercise to him.
Mr J was not interested and said “his leg hurt too much.” In a motivational interview the nurse might ask Mr. J to describe his day and what gave him pleasure and what were the barriers to him becoming mobile and in this way he might be guided to explore his ambivalence about returning to work and identify what is both important and manageable for him.
The nurse also was aware that, faced with Mr J’s intransigence, she had started to argue with him and tell him that he was perfectly able to work again. Arguing in favour of change (returning to work) placed Mr J on the defensive and in a position of arguing against change.
Time was identified as a key barrier to using an MI approach by the PTs and together with the structure of an assessment meant that PTs did not explore with clients their attributions for their sickness or how they could effect changes to their lifestyle. Miller and Rollnick (2012) suggest that a session of 30 minutes is needed to undertake a motivational interviewing session that employs the full range of motivational interviewing techniques and builds rapport and follow – up is also regarded as an important element for encouraging, maintaining and sustaining behaviour change (Miller and Rollnick, 2012 and Rubak et al, 2005).
Reflective listening, the use of open-ended questions and affirmation are central to MI. Reflective listening which involves summarising or reflecting back what is said encourages clients to elaborate and explore their ambivalence about making any change. It demonstrates that nurses are trying to understand clients’ points of view, and lets clients know they’re being heard and accepted. The PTs were familiar with reflective listening but not skilled in demonstrating it.
PTs also mentioned that the focus of MI on motivation could be of core relevance to OH as practitioners need to understand not only what might motivate someone to change an unhealthy behaviour but also motivations about return to work. These elements may be complex.
For some there could be practical barriers to such a return, including difficulties in using public transport following surgery such as a total hip replacement. Another barrier to an effective return could be that currently the client does not have the level of fitness required for a particular post and a time limited phased return to work with modified job requirements could be helpful in this regard.
There may be attitudinal components underpinning a client’s readiness and confidence to return to work. These may be the attitudes of the client or their manager. From a client’s perspective, they may believe that they will be unable to return to work until all their symptoms have resolved and they are what they would consider to be symptom-free and in good health. Discussing and developing a well-planned phased return to work could help their recuperation.
The introductory session introduced rating scales, with which the practice teachers as OHNs were familiar, to assess pain intensity levels. Rating scales are used in MI to evaluate confidence and readiness for change. When clients are asked to quantify their readiness or confidence on a scale of 0 to 10, with 0 meaning not confident at all and 10 meaning most confident, they have to quickly answer. By asking them what it would take for them to increase their score, they focus on elaboration of their motivations and self-efficacy. Asking why they didn’t choose a score that’s three or four less than the one they’ve chosen, practitioners can guide them into positive self-talk, and clients hear themselves arguing in favour of change.
Using rating scales in an occupational health assessment
OHN: “Mr. R, on a scale of 0 to 10, 10 being the most confident and 0 being not confident at all, how confident are you that you’re ready to lose some weight to become more mobile?”
Mr R: “About a 7, I suppose.”
OHN: “Oh so you’re fairly confident. What would it take for you to be a 9 or 10?”
Mr R: “I struggle with my weight and have done all my life. I find it really hard to say “no” to food and I like it.”
OHN: “So food is an important part of your pleasures in life.” (This is simple reflection.)
Mr R: “Yeah, it is. But I know I should lose some weight. It’s really hard with my grandchildren getting about”
OHN: “Your grandchildren are important to you.” (Again, simple reflection.)
Mr R: “They’re my world, and I really want to be around to enjoy them.” (This is change talk.)
OHN: “So back to the confidence scale: Why did you choose a 7 instead of a 5?”
Mr R: “I have lost a lot of weight in the past and kept it off for almost 5 years, so I know that I can do it again.”
OHN: “That’s fantastic! Tell me more about how you did it.” (This is to support self-efficacy.)
The PTs could see from this example how the use of scaling questions and reflective listening could encourage the client to talk easily about their motivations and barriers and get them to express change talk. They saw this requiring them to work in different ways with a client, avoiding simple assessment questions as these lead to simple answers and do not explore motivation. In this example, we can see the client’s ambivalence and how the OHN tries to develop the discrepancy between a love of food and the client’s love of his grandchildren that could be compromised by his obesity.
Most people will be ambivalent about making a change and will need to weigh up the consequences of continuing the status quo compared with the potential advantages of implementing change.
Exploring the pros and cons of current behaviour
OHN: “What are some of the benefits of continuing your current diet?”
Mr R: “I enjoy going out to eat and drink with friends and family and I don’t like to have to think about what I eat or drink”
OHN: “What are some of the cons?”
Mr R: “Well it raises my blood sugar. It’s made me gain weight so I don’t feel good about myself. I get a bit puffed walking up the stairs even to my office.”
OHN: “What would you gain by watching what you eat and cutting back on your portions?”
Mr R: “I’d be able to go out and play football with my grandson. I might get my blood sugar under control and I think I’d feel better about how I looked, a bit more professional.”
OHN: “Those sound like really good reasons for giving it a go. What do you think?”
Most of the practice teachers described giving information as a key part of their practice. In a motivational interview, the practitioner starts from the individual finding out what they already know about their disease or condition, and then clarifies misconceptions.
Clarifying understanding and exploring ambivalence
OHN: “So part of you wants to get your blood sugar under control, but the other part of you wants to keep enjoying meals with friends and family?”
Mr R: “Yeah. It’s just so hard to keep on top of what I eat all the time. Often I just can’t be bothered.”
OHN: “So it seems a lot of effort. What happens 4 or 5 years from now if you don’t get your blood sugar under control? What will that be like?”
Mr R: I suppose it can cause blindness and kidney failure in the long run.”
OHN: “How likely do you think those things are to happen to you?”
Mr R: “I didn’t really think about it before, but I guess I’m more vulnerable than I thought. I don’t want to be off work all the time and definitely not in and out of hospitals or tied to a dialysis machine.”
OHN: “How do you think you can avoid those things?”
Mr R: “I’m going to have to keep my blood sugar controlled and start watching what I eat.”
Conclusion
OHNs are well placed to support employees in making life changes which impact on their health. They interact regularly with a group of people who may not necessarily access other healthcare providers.
The use of motivational interviewing, although currently not central to the approaches of the PTs who were involved in this small-scale study, was mentioned as being of core relevance in the OH setting as OH professionals need to understand what may motivate a client to change unhealthy behaviours and what may motivate them to make an effective return to work.
Most of the participants described information-giving as an important element within their practice but recognised that the use of motivational interviewing techniques could be a powerful approach in assisting the client to understand their health condition and empowering them to take positive steps to improving their health status.
Using motivational interviewing techniques supports behaviour changes congruent with the NICE Public Health guidelines on behaviour change. Currently, for these PTs the use of motivational interviewing is not an integral part of their skill set. Just as the use of cognitive behaviour therapy is increasingly used in the OH setting, motivational interviewing could also become more commonly used within OH practice.
Professor Jane Wills BA, MA, MSc, FRSPH is professor of health promotion at London South Bank University. Professor Anne Harriss MSc, Bed, RGN, RSCPHN, OHNC, NTFHEA, PFHEA, CMIOSH, QN, FRCN is professor of occupational health and course director at London South Bank University
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World Health Organization (2001) The Role of the Occupational Health Nurse in Workplace Health Management. Copenhagen: WHO. Available from: http://www.who.int/occupational_health/regions/en/oeheurnursing.pdf?ua=1
