Implementation of Motivational Interviewing in a diabetes care management initiative in the Netherlands

Abstract

Objective

Motivational Interviewing (MI) is a counseling approach to support behavioural change. The objective of the present study was to examine the uptake of MI in daily practice by health care professionals in a care management initiative for patients with diabetes in the region of Maastricht, the Netherlands.

Methods

MI was implemented by means of a training. Directly and six months after the training, the application of MI was measured objectively (MITI) and subjectively (questionnaire). In focus interviews, MI-trained professionals (n = 10) and MI untrained professionals (n = 10) were asked about facilitators and barriers for implementation. Additionally, data on patient characteristics (n = 141) were collected.

Results

Spirit of MI was present among professionals directly after the training and increased during follow-up. Mostly uncomplicated techniques were applied. Professionals stated the need for training and practice to be able to apply more complicated techniques.

Conclusion

The applicability of MI in daily practice was found feasible, with various degrees of uptake. Relevant conditions to further improve the implementation of MI in daily practice were identified.

Practice implications

In daily practice, a phased training in MI is recommended, with sufficient time and support by colleagues as essential conditions to profit most from the training sessions.

Introduction

In the last decades, a growing insight in the needs of chronically ill has initiated changes in chronic care. Perhaps best known from an international perspective on chronic care improvement is the Chronic Care Model (CCM). It provides a framework for relevant interventions, directed to community and health systems aspects as well as patients and professionals aspects, aiming to improve outcomes and thus supporting these changes [1]. Redesign of health care delivery, more focus on patient empowerment and self-management combined with evidence based, protocol-directed interventions take place [2], [3] and lead to a shift from acute, reactive care to planned, pro-active care for people with chronic conditions [4].

The focus on a pro-active approach demands specific skills of patients (e.g. self-management) and health care professionals (e.g. motivational skills) and therefore, results of interventions should not only focus on medical outcomes, like blood pressure or glycated haemoglobin concentration, but also on barriers and facilitators of implementation of these specific skills.

In the region of Maastricht, the Netherlands, the care for people with diabetes mellitus is organized in a care management initiative, in which patient-centred care is considered a quality dimension. Patient-centred care is defined as “the experience of transparency, individualization, recognition, respect, dignity and choice in all matters without exception, related to one's person, circumstances and relationships in healthcare” [5]. Consequently, patients are encouraged to self-management. Delivery of care and coordination of care is further supported by the introduction of an electronic, web-based patient record.

Care is carried out by a multidisciplinary team of primary and secondary health care professionals. The general practitioner (GP), supported by practice nurses and dieticians, is primarily responsible for the majority (85%) of the people with diabetes type 2. A team of internist, endocrinologist, diabetes specialist nurse, dietician and ophthalmologist, employed by the Maastricht University Medical Centre (MUMC), is primarily responsible for people with diabetes type 1 and for people with diabetes type 2 in need for complex care. The team of the MUMC also has a consultative role for GPs in case of inter-current health problems in their patients. The involved health care professionals collaborate in an alliance (DIAMAND), responsible for the multidisciplinary protocols, patient allocation and quality of care [6].

Life style has an important impact on the course of diabetes. Life style interventions lead to improvement in glucose tolerance [7] and life style induced changes in insulin resistance are strongly related to fatty acid profiles [8]. One of the components to improve healthy life style is the behaviour of persons with diabetes. To support this, several methods are available with motivation being regarded as essential for all of them [9], [10].

Motivational Interviewing (MI) is a directive, client-centred counseling style, designed to elicit behaviour change by helping people to explore, clarify and resolve ambivalence to this change [11]. Ambivalence is of main importance in the process of change. Assessment of advantages and disadvantages of current behaviour and intended behaviour is considered a key to change. Therefore, the counselor is intentionally directive in pursuing this goal [11], [12]. In nature (the spirit), MI encourages people to identify their own attitudes and behaviour, related to the state of health, and to explore their barriers with regard to change, thus evoking intrinsic motivation. The counselor facilitates this process and supports the person in setting realistic targets for behavioural change [11]. Both client and counselor are equal partners in the process of change. Expressing empathy, developing discrepancy (increasing the difference between current and intended behaviour), moving with resistance, avoiding discussion and supporting personal effectiveness are basic principles of MI [12]. Necessary skills to apply these basic principles are [12]:

• ask open questions;

• summarize the elements of the conversation;

• support and confirm the client during the care process;

• elicit change talk;

• listen reflective.

The application of these skills facilitate to respond to change talk (discussing opportunities and expectations for change) and to resistance of the client [12].

MI has been applied in a variety of settings and on various client groups and yields positive results [13], [14], [15]. Also with regard to people with diabetes, MI positively influences treatment results [16], [17], [18]. However, it is not always clear what the intervention involves or how it is modified for a specific population. Furthermore, it is unclear how much training is needed for competent appliance of MI and how patient characteristics may influence the implementation of MI [19]. Therefore, the research issue addressed in this article was focussed on various facets of the process of implementation of MI in the diabetes care management initiative in Maastricht. Additionally, data on patient characteristics were collected to profile the population of diabetes patients in this initiative.