The feasibility of motivational interviewing as an adjunct to pulmonary rehabilitation to promote engagement and adherence to physical activity recommendations

Abstract

Aim: To explore the feasibility of motivational interviewing (MI) as an adjunct to pulmonary rehabilitation (PR). Method: A mixed methods research design was used, involving three linked studies, guided by the Medical Research Council complex intervention framework. Study 1: following a 1-day introductory workshop, respiratory clinicians’ (n=9) views of MI were gathered, and their insights informed a model for combining MI with PR, and a MI training package. Study 2 employed a pre-post, single group quantitative design to evaluate the effectiveness of the MI training package (2-day workshop and five
coaching/feedback sessions) for PR clinicians (n=24). The learning and implementation experiences of a sample of these participants (n=9) were explored in study 3. Results: Study 1: Respiratory clinicians deemed MI acceptable for maximising PR engagement and adherence but raised feasibility issues regarding training and implementation. Study 2: PR clinicians made progressive improvements in MI skill at each stage of training, with mean values for MI spirit (3.5 ±0.61) and mean global ratings of skill
(3.57±0.63) reaching basic competency targets (3.5). The relative frequency and depth of reflective listening did not alter sufficiently (reflection question ratio 0.71 ±0.40, target 1; percent complex reflections 24.25 ±13.54, target 40) and participants struggled to achieve the depth of conversation advocated in the PREAMP intervention manual developed for the study. Participants took longer than expected to complete training (total training time 20.55 weeks ±9.78, target 10 weeks) and n=12 (50%) did not complete training. Study 3 highlighted three themes. Within these are some possible explanations for the failure to achieve desired levels of reflective listening, depth of conversation and timely completion of training within study 2: 1) Cultural context: service/organisational issues result in prioritisation of short-term measures of impact, which compromise the time available for MI. A disconnect exists between an MI style of working and the approach that PR clinicians are used to and feel comfortable with; 2) Challenging: the prospect of using novel skills led to performance anxiety. Using MI required participants to accept that sessions may take longer, cover unanticipated topics and may not result in change. Concerns were raised that not all patients are immediately ready to take a more active role in consultations and decision making. Trying novel skills and suppressing behaviours that are antithetical to MI demanded attentional resource and detracted from key tasks such as maintaining empathy. Participants found recognising the limitations of existing practice, yet feeling underprepared to deliver MI effectively, to be destabilising. MI may reveal emotive issues that are uncomfortable for both patients and clinicians. However, all participants noted improvements in their skills and confidence over time, which reinforced positive perceptions of MI; 3) Lessons learnt for the future: training was well received but greater volume of training, protected time for learning and extended appointments to support the integration of MI in practice were deemed important. Conclusion: MI maybe a feasible adjunct to PR. It can be delivered by health professionals, but there are some training issues that need to be addressed to ensure competence. The next stage in the MRC framework should be a pilot randomised controlled trial, but the author recommends use of a stepwise training model whereby training continues until basic competency is achieved, and that additional appointment time is provided to allow for the integration of MI.

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ORCID for Anne Bruton: orcid.org/0000-0002-4550-2536

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