New ways of dealing with patients using evidence-based strategies can lead to greater adherence and job satisfaction.
Effective communication with patients and clinical colleagues is a fundamental aspect of a pharmacist's practice. With the patients I work with, those with severe and persistent mental illnesses, behavioral changes such as tobacco cessation, exercising, proper nutrition, and medication adherence would often bring about profound changes in their well-being—if the patient would simply adopt these changes. Getting to that point is often a significant barrier and a source of frustration, as repeated attempts to engage patients to change end in failure.
Convincing a physician or administrator to make a clinical policy change, a formulary addition, or a practice change can be just as challenging. The day-to-day challenge of being ineffective can lead to long-term frustration, cynicism, and professional burnout.
Our health care training has often led us to believe that physicians, pharmacists, and nurses are at the pinnacle of the health care team. As “all-knowing,” they simply have the task of pointing out to patients what they are doing wrong and what they need to do differently to improve their health and well-being.
It is becoming increasingly clear that dictating directives to patients is a highly ineffective strategy. I like to think of it as “The ‘60s are over and Vince Lombardi is dead!” Commanding patients what to do unilaterally, fear and intimidation tactics (“If you do not lose weight you will develop diabetes, hypertension, joint disease, etc”), and giving pointed advice without permission are strategies that are doomed to fail. Further, it will add to the clinician’s frustration regarding their relative inability to be successful in changing a patient’s behavior and health outcomes.
Motivational interviewing (MI) is an evidence-based strategy that is included in the Substance Abuse and Mental Health Services Administration’ s listing of effective patient care programs. MI incorporates strategies of understanding the patient where they are—via active listening, empathy, respect, and collaboration with the patient on developing and achieving incremental goals. MI is not an intuitive process. On the contrary, it often runs counter to our training as health care providers as being “all-knowing.”
Effective implementation of MI techniques requires basic training and skills development, then repeated practice. Ongoing feedback via trained supervision has been found to best assure that the principles of MI are adhered to over time.
MI uses active listening skills to identify what motivates a patient. The issue becomes one of “What is the patient motivated for?” instead of “Why isn’t the patient motivated?” MI is based on the concept that people are more often “stuck” versus totally opposed to change. As health care providers, pharmacists are in a unique position to positively influence someone’s motivation via applying the techniques of MI.
Quite simply, MI is the effective use of open-ended questions to identify where the patient is in relationship to considering a change in behavior. There are suggested to be 6 stages in the change continuum—pre-contemplation, contemplation, preparation, action, maintenance, and relapse. As the primary experts on themselves, patients are in the unique position of taking action to help themselves. Empowering the patient to see the world from this perspective can help him or her to begin to take action.
The cardinal rule of MI—using the acronym RULE (offered up by Miller, Rollnick, and Butler, 2009)—is to R
esist the righting reflex (ie, telling the patient what to do or being judgmental), U
nderstand your patient’ s motivation, L
isten to your patient, and E
mpower your patient.
Initially, the use of MI may feel cumbersome and may take more time versus the old unilateral advice giving practices. In time, with continued practice and coaching, the skills will become more entrenched. It may always be difficult for some of us to remain neutral and non-judgmental, and to refrain from responding to poor decision making by patients. Transferring the responsibility for success from the provider to the well-informed and change-ready patient can be an effective tool for the pharmacist—and can lead to enhanced professional satisfaction.
Jerry McKee, PharmD, MS, BCCP, is associate director of Behavioral Health Pharmacy Programs Community Care of North Carolina.