Estonian experience in

teaching Motivational

Interviewing for medical

providers

Anneli Rätsep PhD

GP

senior researcher

Department of Family Medicine

University of Tartu

Doctor’s expectations that

patient... • Knows carbohydrate content of their food

• Monitors the fat content of their diet (cholesterol)

• Takes properly medication for lowering blood

sugar, cholesterol and blood pressure

• Is able to inject insulin

• Measures blood glucose level and blood

pressure at home and keeps the diary

• Is physically active more than 150 minutes at

least five days a week

• Visits regularly to the doctor and nurse

“Rightning reflex”

• I have to show to my patient the problem

of his/her behavior

• I have to give information, so my patient

will understand the problem

• I have to teach to my patient some skills,

so that he can change his behavior

• I have to scare my patient enough, so he

will change his behavior.

Rollnick S, Miller WR, Butler C. Motivational interviewing in health care : helping patients change behavior. New York: Guilford Press, 2008.

Patients’ perceptions

P5: „One should take medication as much as needed but as little as possible.” P5: „ I haven’t accepted the idea of talking about it, I am not interested in it (insulin therapy). If I was interested then may-be I would talk about it, then I would ask. Yes I’d rather ask myself, but I am not interested.“

P1: „I have diabetes and I am like on a leash, let’s say I am on a leash of doctor. There are moments when I think that I do not want to be on a leash all the time”

“If you are arguing for change and

your patient is arguing against it, you’ve

got it exactly backward”

(Miller & Rollnick, 2013)

What has changed?

„The most common criticism made at

present by older practitioners is that young

graduates have been taught a great deal

about the mechanism of disease, but very

little about the practice of medicine – or, to

put it more bluntly, they are too “scientific”

and do not know how to take care of

patients.“

Peabody, F. Journal of the American Medical Association

(JAMA 1927; 88:877-882)

What can be done

differently?

• Time

• Caring

• Emphaty

• Compassion

Peabody, F. Journal of the American Medical Association

(JAMA 1927; 88:877-882)

MI Patient centred

Communication style

Goal oriented

Eliciting and exploring

person’s own reasons for

change

Dealing with ambivalence

Rollnick S, Miller WR, Butler C. Motivational interviewing in health care : helping patients change behavior. Third edition New York: Guilford Press, 2013.

Teaching MI

• Behavioural component

• Technical skills – OARS

– Open ended questions

– Affirmations

– Reflective listening

– Summarising

Spirit of Motivational interviewing

Partnership

• Absolute worth

• Empathy

• Autonomy

• Affirmation

Acceptance

Compassion

Evocation

Rollnick S, Miller WR, Butler C. Motivational interviewing in health care : helping patients change behavior. Third edition New York: Guilford Press, 2013.

Is there an evidence? • More than 200 RCT-s

• Armstrong et al. Motivational interviewing to improve weight loss in overweight and/or obese patients: a systematic review and meta-analysis of randomized controlled trials. Obes Rev. 2011

• Brodie et al. Motivational interviewing to change quality of life for people with chronic heart failure: a randomised controlled trial. Int J Nurs Stud. 2008.

• Vasilaki et al. The efficacy of motivational interviewing as a brief intervention for excessive drinking: a meta-analytic review.

• Alcohol Alcohol. 2006

• Rubak S, et al. Motivational interviewing: a systematic review and meta-analysis. Br J Gen Pract. 2005

Estonia

12

• 25 245 health care

personnel (1884 to

100 000 inhabitants)

• 4323 doctors,

among them ~1000

family doctors )

• 8805 nurses

Retrospect on teaching of MI

in Estonia (1999-2010) • 1999 - The first course „Instructions to the

Theory and Practice of Motivational

Interviewing“ (20 psychiatrists and

psychologists)

• 2003 - basic training and 2006 - “Train-the-

trainers of Motivational Interviewing” for prison

specialists

• 400 prison specialists have passed 3-day basic

courses during the years

Retrospect on teaching of MI

in Estonia (1999-2010) • Special research group of assessment and

evaluation system of Motivational Interviewing

Treatment Integrity Code was organised

• The Association of the Trainers of the Motivational

Interviewing in Estonia (EMITA) was organised -

21 members from different specialities

• 5 trainers are members of Motivational

Interviewing Network of Trainers

http://www.motivationalinterviewing.org/trainer-listing

Breakthrough in health care

• 2009 – survey among the primary health care

specialists (nurses, GPs, occupational therapist)

• Project of Health Development Institute and ESF

(European Social Fund)

• MI international trainers: Michael Beltenburg, Sven

Wåhlin, Tim Anstiss, Judit Carpenter, Erik

Knifström, Jeff Breckon

• 3 MI trainers - MINT members from Estonia

• 6 GPs (5 of them members of Department of the

Family Medicine at the University of Tartu)

Motivational Interviewing

in Health Care“

– in Estonian

Courses for medical personnel

2010-2014

MI introduction (8h)

33 courses - ~700 participants

Counselling on alcohol consumption (8 h)

27 courses

Councelling for healthy life style (16 h)

19 courses

Skills development 16 h+ 8h with MITI coding and

feedback

6 courses

Narrative feedback

• „Good decriptive, memorable exercises,

help better understand the theory“

• „I like the form of learning, adequate tempo,

good involvement of the participants“

• „Group work was suprisingly successful for

my I am usually shy in a new environment“

• „Very good, emphatic and supporting

trainers“

Narrative feedback

• „It was liked that the trainers practice

themselves and used good examples from

real life“

• „Reflection was new for me – interesting!“

• „MI is self-preserving“

• „I had the chance to do practical

excercises and realised how difficult it is to

find the right words“

Conclusions • The learning process was highly

appreciated by the trainees

• MI is included to the training of residency

trainees in family medicine in Estonia

• 6th year undergraduates - 4 hours seminar

• Positive feedback motivates trainers to

learn more and continue with teaching

• Training of trainers continues

• In the future we hope to start with

continuous training for already trained

medical personnel

Thank you for your

attention!