Toward an Emerging Role for Motivational Interviewing in Primary Care

Patient concerns and physician strategies for addressing COVID-19 vaccine hesitancy

OBJECTIVE

COVID-19 vaccination is critical for reducing serious illness and hospitalizations, yet many remain hesitant. We conducted a survey of frontline physicians to identify patient concerns and physician strategies to address COVID-19 vaccine-hesitancy.

METHODS

A national random sample of physicians in frontline specialties selected from a comprehensive list of practicing physicians in the U.S. were emailed a survey in August 2021. Multiple choice and open-ended questions inquired about patient concerns related to the COVID-19 vaccines and strategies used by physicians to counter vaccine misinformation and encourage vaccine-hesitant patients. Weighting was applied to achieve representativeness and reduce non-response bias. Network analysis examined co-occurring patient concerns. Open-ended responses on communication strategies were coded via thematic analysis. Multi-variable logistic regression examined associations between physician and pandemic characteristics with patient concerns and use of communication strategies.

RESULTS

531 physicians responded: primary care (241); emergency medicine (142); critical care (84); hospitalists (34); and infectious disease (30). Weighted response balance statistics showed excellent balance between respondents and nonrespondents. On average, physicians reported four patient vaccine concerns. Safety, side effects, vaccine misinformation, and mistrust in government were most common, and often co-occurring. 297 physicians described communication strategies: 180 (61 %) provided vaccine education and 94 (32 %) created a safe space for vaccine discussion. Narrative responses from physicians provided compelling examples of both successes and communication challenges arising from misinformation. Compared with emergency medicine, critical care (OR 2.45, 95 % CI 1.14, 5.24), infectious disease (OR 2.45, 95 % CI 1.00, 6.02), and primary care physicians (OR 1.66, 95 % CI 1.02, 2.70) were more likely to provide communication strategies.

CONCLUSIONS

Many physicians engage with vaccine hesitant patients using a variety of strategies. Dissemination of effective system and physician-level communication interventions could enhance physician success.

Implementing a workflow-integrated motivational interviewing training program for psychiatry trainees on an inpatient consultation-liaison rotation: lessons learned

Background

Effective consultation-liaison psychiatry (CLP) is proactive, collaborative, and requires providers to have proficiency with therapeutic skills beyond nosology and medication management. Motivational interviewing (MI) is an evidenced-based intervention that should be considered essential for CLP trainees to learn. Given that the demands of training and patient care are already experienced as stressful for many psychiatry trainees, the authors endeavored to create a MI training program that was integrated into trainees' normal CLP workflow.

Method

Twenty-two trainees on an inpatient CLP rotation participated in a six-week MI training program that was incorporated into their regular workflow. The program included didactic sessions with role-playing, as well as on-demand between-session coaching via an expert in MI. Trainee participation and perceptions of MI were measured via a questionnaire that was administered prior to each training session.

Results

Trainee participation in the didactic sessions was inconsistent. Questionnaire data revealed positive baseline perceptions of motivational interviewing and its usefulness in inpatient medical settings. Additionally, as trainees participated in the program, perceived knowledge of motivational interviewing as well as awareness of motivational issues among their patients increased. Finally, participation in program was not perceived as disruptive to daily workflow for the participants.

Discussion

This the first documented attempt at implementing a MI training program for CLP trainees that was integrated into their regular workflow. Preliminary data identified some encouraging trends, but also unexpected challenges. These lessons could inform how these types of training programs are implemented moving forward.

Elements of Integrated Behavioral Health Associated with Primary Care Provider Confidence in Managing Depression at Community Health Centers

BACKGROUND

Depression is most often treated by primary care providers (PCPs), but low self-efficacy in caring for depression may impede adequate management. We aimed to identify which elements of integrated behavioral health (BH) were associated with greater confidence among PCPs in identifying and managing depression.

DESIGN

Mailed cross-sectional surveys in 2016.

PARTICIPANTS

BH leaders and PCPs caring for adult patients at community health centers (CHCs) in 10 midwestern states.

MAIN MEASURES

Survey items asked about depression screening, systems to support care, availability and integration of BH, and PCP attitudes and experiences. PCPs rated their confidence in diagnosing, assessing severity, providing counseling, and prescribing medication for depression on a 5-point scale. An overall confidence score was calculated (range 4 (low) to 20 (high)). Multilevel linear mixed models were used to identify factors associated with confidence.

KEY RESULTS

Response rates were 60% (N=77/128) and 52% (N=538/1039) for BH leaders and PCPs, respectively. Mean overall confidence score was 15.25±2.36. Confidence was higher among PCPs who were satisfied with the accuracy of depression screening (0.38, p=0.01), worked at CHCs with depression tracking systems (0.48, p=0.045), had access to patients' BH treatment plans (1.59, p=0.002), and cared for more patients with depression (0.29, p=0.003). PCPs who reported their CHC had a sufficient number of psychiatrists were more confident diagnosing depression (0.20, p=0.02) and assessing severity (0.24, p=0.03). Confidence in prescribing was lower at CHCs with more patients living below poverty (-0.66, p<0.001). Confidence in diagnosing was lower at CHCs with more Black/African American patients (-0.20, p=0.03).

CONCLUSIONS

PCPs who had access to BH treatment plans, a system for tracking patients with depression, screening protocols, and a sufficient number of psychiatrists were more confident identifying and managing depression. Efforts are needed to address disparities and support PCPs caring for vulnerable patients with depression.

Factors Associated with Tobacco Cessation in Primary Health Care

Introduction  Cigarettes are the main cause of preventable death in the world, and primary health care services can contribute to the management of this habit. Objective  To describe and analyze the factors associated with tobacco cessation in groups of smokers in primary health care. Methods  The present is a cross-sectional study conducted in 12 primary health care units from July 2016 to May 2017. We investigated sociodemographic and health variables, as well as smoking characteristics and different interventions for tobacco cessation, with the outcome being studied and analyzed after the fourth group care session. Results  We evaluated 329 smokers, of which 182 quit smoking after the fourth interview. Most of the individuals who quit smoking were women ( n  = 121, 66.5%), with a monthly income of 2 to 5 minimum wages ( n  = 88, 77.9%). After the multivariable analysis, we observed that tobacco cessation was significantly associated with depression (prevalence ratio [PR] = 1.11; 95% confidence interval [95%CI] = 1.02 to 1.22), as well as with belonging to the groups which used as approaches motivational interviewing (PR = 1.21; 95%CI = 1.13 to 2.01), patches (PR = 1.36; 95%CI = 1.24 to 1.48), and bupropion (PR = 1.16; 95%CI = 1.03 to 1.31). Conclusion  Primary health care is the ideal site for the reduction of smoking rates, given that different technologies may be applicable and useful for tobacco cessation. The comprehensiveness and longitudinal care offered in primary care may provide opportunities for health professionals to understand which is the best technology for each health system user, thus contributing to personalized care.

Does education of primary care professionals promote patient self-management and improve outcomes in chronic disease? An updated systematic review

BACKGROUND

Primary care has a vital role in supporting patient autonomy to enable people with long-term conditions to manage their own health and wellness. Evidence is needed on whether education and training of health professionals helps support patient self-management and improves outcomes. The authors' first systematic review included only two articles showing patient outcomes following health professional training for promoting patient self-management.

AIM

To present an updated review undertaken from September 2013 to August 2018.

DESIGN & SETTING

A systematic review was undertaken using the PRISMA guidelines, following the methodology of the first review and is outlined in the PROSPERO registered protocol.

METHOD

Six databases were searched - Cochrane Library, PubMed, ERIC, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and PsycINFO - in addition to web searches, hand searches, and bibliographies for articles published from 1 September 2013 to 31 August 2018.

RESULTS

The updated systematic review showed more evidence is now available with 18 articles in the 5-year period from the 4284 abstracts located. Twelve of these articles showed a difference between intervention and control groups. Of the 18 articles identified, 11 were assessed as having a low risk of bias and five overall were rated of weak quality. The educational interventions with health professionals spanned a range of techniques and modalities, and many incorporated multiple interventions including patient components. There may be a lack of adoption owing to several challenges, including that complex interventions may not be delivered as planned and are difficult to assess, and owing to patient engagement and the need for ongoing follow-up.

CONCLUSION

More high-quality research is needed on what methods work best, for which patients, and for what clinical conditions in the primary care setting. The practical implications of training healthcare professionals require specific attention.

Moving from "let's fix them" to "actually listen": the development of a primary care intervention for mental-physical multimorbidity

BACKGROUND

Effective person-centred interventions are needed to support people living with mental-physical multimorbidity to achieve better health and wellbeing outcomes. Depression is identified as the most common mental health condition co-occurring with a physical health condition and is the focus of this intervention development study. The aim of this study is to identify the key components needed for an effective intervention based on a clear theoretical foundation, consideration of how motivational interviewing can inform the intervention, clinical guidelines to date, and the insights of primary care nurses.

METHODS

A multimethod approach to intervention development involving review and integration of the theoretical principles of Theory of Planned Behavior and the patient-centred clinical skills of motivational interviewing, review of the expert consensus clinical guidelines for multimorbidity, and incorporation of a thematic analysis of group interviews with Australian nurses about their perspectives of what is needed in intervention to support people living with mental-physical multimorbidity.

RESULTS

Three mechanisms emerged from the review of theory, guidelines and practitioner perspective; the intervention needs to actively 'engage' patients through the development of a collaborative and empathic relationship, 'focus' on the patient's priorities, and 'empower' people to make behaviour change.

CONCLUSION

The outcome of the present study is a fully described primary care intervention for people living with mental-physical multimorbidity, with a particular focus on people living with depression and a physical health condition. It builds on theory, expert consensus guidelines and clinician perspective, and is to be tested in a clinical trial.

Feasibility of Using Communication Coaching to Teach Palliative Care Clinicians Motivational Interviewing

CONTEXT

Palliative care clinicians often have challenging conversations with patients or family caregivers who express ambivalence about goals or feel reluctant to discuss topics. Motivational Interviewing (MI) has tools to address ambivalence and reluctance.

OBJECTIVE

The aim of this pilot study was to test the feasibility, acceptability, and preliminary efficacy of an MI communication coaching intervention.

METHODS

We enrolled 22 palliative care clinicians and randomly assigned half to receive communication coaching versus wait-list control. The coaching entailed a lecture on MI, a 1:1 session to discuss applying MI, and audio recording and receiving feedback on four encounters (two separate times). Palliative care clinicians in the wait-list control arm audio-recorded four encounters. Coders blinded to study arm coded MI behaviors. We surveyed patients, caregivers, and clinicians after all audio-recorded encounters to assess perceptions of the encounter. The analyses were performed using a repeated-measures mixed model.

RESULTS

We found the intervention to be feasible and acceptable. Eighty-six percent of those enrolled completed all study activities including coaching sessions, audio-recording encounters, and completing surveys. Of those in the intervention arm, 88% rated the intervention as helpful and 100% would recommend it to a colleague. Compared to control clinicians, intervention clinicians had higher ratings of their MI skills after intervention, higher objectively rated communication skills, and slightly better burnout scores. We found no arm differences in patient, caregiver, or clinician ratings of satisfaction.

CONCLUSION

This pilot study indicates that coaching palliative care clinicians is feasible and shows promise that coaching can improve palliative care clinician communication.

Embedding and sustaining motivational interviewing in clinical environments: a concurrent iterative mixed methods study

BACKGROUND

Motivational interviewing (MI) is internationally recognised as an effective intervention to facilitate health-related behaviour change; although, how it is best implemented and maintained in everyday clinical practice is not so clear. The aim of this study is to understand how MI as an intervention can be embedded and sustained in the clinical practice and learning environments.

METHODS

A concurrent iterative mixed methodology was utilised. Data collection occurred in two parts: a scoping review to identify reported barriers and enablers to embedding and sustaining MI in healthcare settings, and a survey of health professionals at an international clinical educator workshop on the topic. Results from both methods were integrated at the analysis phase ('following a thread') to understand how MI is embedded and the fidelity sustained in the clinical environments. Complexity theory as a conceptualising framework was utilised.

RESULTS

Eleven studies were included, and 30 health professionals were surveyed. Sustainability of MI at micro-clinical levels can be fostered through use of enabling technology, focus on patient-centred care, personnel development and process improvement. At the meso-organisational level, developing shared vision, creating opportunities and an organisational culture supportive of continuous learning are relevant issues. At the macro levels, adopting systems thinking and a learning organisation approach is important for sustaining MI.

CONCLUSIONS

In addressing the recognised barriers to embedding and sustaining MI in health service provisions, clinical educators could potentially play a central role as change agents within and across the complex clinical system.

NP student encounters with obesity bias in clinical practice

This study explores NP students' encounters with obesity stigma and bias in their clinical environment as well as recommendations to decrease obesity stigma and bias. Results indicate a need for continued education on the topic of weight management within NP curricula.