Using simulation-based training to improve health conversations by developing motivational interviewing in clinical support workers

Summary

This article describes the effectiveness of using a mixed method approach incorporating simulation-based training (SBT) to improve awareness of and skills in motivational interviewing (MI) to promote conversations with patients about health behaviours. The course was delivered to apprentice clinical support workers (CSWs) working in mental health settings across South London.

Background

MI is an evidenced-based psychosocial intervention used to enhance intrinsic motivation to facilitate behaviour change in a non-coercive manner by exploring and resolving ambivalence (Miller and Rollnick as cited by Martins and McNeil).¹ First ‘developed’ in 1983 by William Miller, it was initially used to help those with substance misuse.

At its core, MI combines a non-judgemental person-centred approach, with listening and communication skills, to help build self-efficacy and strengthen the person’s own ideas, reasons and need for change. It works on the principle that behavioural change is most successful when driven from within, rather than imposing external beliefs.

There is increasing evidence for its application in a wide variety of health areas, including weight-loss, blood pressure, smoking cessation, gambling, treatment compliance, diabetes management and oral health (further references).^{1 2}

Training methods in MI vary in modality, degree of passivity and length. There is little conclusive evidence to suggest one modality is more effective than another,³ though the quality of practitioner skills may be linked to the effectiveness of the intervention.

SBT is increasingly being used in healthcare education. Its benefits are widely recognised, not least due to the ability to practice in a safe yet realistic environment. It is particularly suited to developing clinical and non-technical skills such as communication. The modality is thus well suited to developing the skill sets fundamental to MI.

This study focus’ on the benefits and acceptability of a mixed-methods training intervention, incorporating high-fidelity simulation, to enhance CSW knowledge and skills in MI. While CSW’s spend a large proportion of time with patients, they receive very little training despite being crucial in supporting and building strong therapeutic alliances.

Method

‘Healthy lives—an introduction to motivational interviewing’ ran twice at Maudsley Simulation from May to June 2018. The 2-day course had 1 week’s gap between sessions. Day 1 included a mix of individual, pair and group tasks, in addition to didactic teaching introducing the philosophy, principles and skills of MI.

Day 2 involved applying the principles and techniques learnt in a formal setting through simulated scenarios, followed by a skills based debrief designed around Pendleton’s model of feedback. The simulated scenarios used trained actors to portray different health behaviours and demonstrate various degrees of ambivalence to change (table 1).

Table 1.

Summaries of clinical cases

Cases	Scenarios	Description	Aim
1	1–3	Discharge planning—46-year-old man, awaiting discharge, was admitted following relapse in schizophrenia.	Using MI techniques, explore potential social activities postdischarge, his commitment to change and develop a plan,
2	4–6	Medication compliance—50-year-old man admitted due to relapse of psychotic illness, related to poor medical compliance.	Using MI techniques explore willingness to take medications,
3	7–9	Alcohol use—40-year-old woman with bipolar affective disorder, experiencing a relapse in mania, worsened by alcohol.	Using MI techniques explore relationship with drugs and alcohol.
4	9–12	Relationship support—middle age woman with chronic dysthymia and low self-esteem, uncertain about abusive relationship.	Using MI techniques explore feelings towards current relationship and help develop plan.

MI, motivational interviewing.

Participants

Participants (n=21, 69% female, 31% male) were CSW’s undertaking a ‘Level 2 Healthcare Support Worker Apprenticeship’ in South London. The average age of participants were 36 years old and ethnicity varied (Black/African/Caribbean—46%, White 38%, Asian 8%, other 8%).

Evaluation

Two months’ postcompletion of training, eight participants voluntarily participated in a 60 min focus group designed to understand their experience of the training, what they may have learnt, and how they may have used this in their roles. The focus group was transcribed verbatim and analysed using thematic analysis with emergent themes identified: communication, listening skills, confidence and realism.

Findings

Participants discussed improvements in communication skills including using open and closed questions, non-verbal communication and exploring topics in more depth.

I use more open questions & the patients open up more.I explore with my patients what they really want and help them think about changes.

Participants described improvements in their listening ability, which resulted in improved interactions and conversations with patients.

Having direct conversations & paying attention to what is being said.I really listen. Now I think before I speak.

They also spoke about an increase in confidence in; starting challenging conversations, knowing what to say and how to say it. Participants spoke about the impact it had on their ability to build rapport.

I have the confidence to start difficult discussions.I know what & how to say something to patients.

Participants highlighted that the experiential nature of the training was engaging and helped foster development. The use of actors as human simulated patients and the sophisticated design of the scenarios made the training realistic and transferable to workplace settings.

You really have to apply yourself with simulation. Use of actors is very powerful—It’s a real-life situation. This linked to a development in understanding MI, its application in a patient centred approach and how it can impact behaviour change.

Discussion

The findings suggest using high-fidelity SBT as a way to enhance communication skills and embed MI into clinical practice can be an effective approach to training. It is postulated that these benefits are related to participant’s ease and ability to transfer concepts and practical skills into real-life working situations, through the realism simulation training offers and the opportunity to practice and get feedback. At 2-month’s follow-up, participants recognised benefits in communication techniques, listening skills and confidence in starting difficult conversations.

This study also demonstrates the value of training CSW’s, who due to the nature of their role, are often in positions to make meaningful behavioural interventions.

Future research could consider the benefits of this training modality, compared with others, as well as on observed practice and patient lifestyle changes.

Statements

1. The demographic information (age, gender and ethnicity) detailed above are not from actual patients and was gathered using an anonymous online survey used for evaluation purposes. Any resemblance to real person living or deceased will be coincidence.

2. This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors

3. All authors declare that they have no conflict of interest.