Learning to meet my patient where they are at – how letting go changed my practice

Michelle C. Danda, RN, MSN, MPN, BN (biography, no disclosures) VCH Staff Registered Nurse, Mental Health and Addictions Nurse

What I did before

I have been a mental health and addictions nurse since 2008. In the first five years I worked primarily in inpatient setting, with people living with both mental health and substance use issues (Concurrent Disorders). I enjoyed the work, providing care for marginalized people, people living in poverty, with multiple mental and physical health issues. During those first five years I would come home physically and mentally exhausted, feeling defeated by the barriers that each patient seemed to face at every turn. Looking back, much of my time and efforts were focused on trying to make changes in areas I had no power to change: the system, poverty, even my patient’s values and beliefs. My desire came from a noble place of wanting to help each patient make the “right” decision, but my approach was misguided.

I was trying to force change on patients who were really ambivalent and undecided about changing their substance use or following prescribed treatments for their mental health diagnoses. They may have been clearly voicing reasons for continued use, but my focus on trying to help them stop, clouded my ability to listen. I was so disheartened that so many patients did not simply follow the advice and direction of the health care team. I felt overwhelming moral distress as I saw patients experience relapse after relapse.

What changed my practice

Fortunately, much needed education in Motivational Interviewing, the Psychosocial Recovery Model and the Tidal Model, changed my practice (links at the end of the article). I realized that my distress was a direct result of my focus on forcing patients to achieve the outcome that I wanted, while missing the most important piece of patient care, building the relationship, listening to their needs and goals, and realizing that my role was to support them in making their own health care decisions.

I learned that the skill of active listening from a place of genuine curiosity was key, rather than advice giving. I learned to reflect on my own judgments and set them aside, recognizing that my experiences were not my patients’. I hold expertise in certain health care topics, but the patient is the expert in their personal experiences. I realized that engagement is paramount when working with an ambivalent patient, because the change that they want to make is often important in their life, even if the clinician views it as a problem behavior. Motivational interviewing education for inpatient mental health nurses has been shown to improve patient alliance and treatment adherence (Mallisham & Sherrod, 2017).

What I do now

1. Engage

Today, my practice is focused on patient engagement and building a trusting relationship to understand patient’s perspective. For example, I may believe that a patient who has been evicted from their housing or lost their job as a result of substance use should want to stop using. However, they may identify benefits of substance use such as increased energy, creativity, or alleviation of boredom, and they may be seeking help because others have told them that their substance use is causing problems. In these instances, the clinician must endeavor to understand the client’s experience from the client’s perspective. The first step in building rapport and a trusting relationship is engagement (Rollnick & Miller, 1995).

2. Explore perspectives

Clinicians sometimes jump from engagement directly into planning, because they are in the “expert” role, often feeling the need to provide solutions to the problem. We get caught up in wanting to provide information and advice, intending to help our patients move along to make the change, without first exploring the significance and meaning of that change and our patients’ perspectives. Questions I ask to explore my patients’ perspectives are:

• Who is important to you?
• What do you believe you need right now in order to start to feel better?
• What can I or the nursing team do that you may find helpful? (Barker & Buchanan-Barker, 2010).

3. Let them lead

In a resource-limited health care landscape, we are often hurriedly trying to solve patients’ problems, which can lead to establishing a plan before developing a trusting relationship. I learned that, to avoid premature action planning, it was imperative that I endeavor to work collaboratively with my patients, letting them lead. I now resist the urge to give my patient the right answer or well-meaning advice right away.

1. One strategy I use is simply using silence in my assessment, providing space for the client to speak.
2. I learned to use reflection and ask questions with genuine curiosity, to better understand motivations.
3. I found that consciously slowing down my pace and bringing my focus to being in the moment, improved the sincerity of each interaction, and increased my awareness if the patient became disengaged, or demonstrates signs of resistance.

I also learned to ask about patient’s strengths from a person-centered perspective. For example asking:

• What can you do to help to resolve this problem?
• Tell me about things that are important to you.
• How will you or others know when it is getting a bit better?
• What do you think this means?
• Given what you have told me, what do you think this that says about you as a person?

4. Stay present and let go

Through learning Motivational Interviewing I learned to be in the moment with each patient, seeing their experiences from their perspective, and letting go of my attachment to a particular outcome. In your own practice, when you start feeling like you are frustrated and disappointed, take a step back and reflect on whether the change you want to see is wanted by you or your patient. Take a moment to focus on engagement, be curios and connect with your patient.

References:

1. Mallisham SL, Sherrod B. The spirit and intent of motivational interviewing. Perspectives in Psychiatric Care. 2017;53(4):226-233. DOI: 10.1111/ppc.12161. (View with CPSBC or UBC)
2. Rollnick S, Miller WR. What is motivational interviewing? Behavioural and Cognitive Psychotherapy. 1995; 23(4):325-334. DOI: 10.1017/S135246580001643x. (View with UBC)
3. Barker P, Buchanan-Barker P. The tidal model of mental health recovery and reclamation: application in acute care settings. Issues in Mental Health Nursing. 2010;31(3):171-180. DOI: 10.3109/01612840903276696. (Request with CPSBC or view with UBC)

Resources:

1. Motivational Interviewing Network of Trainers: https://motivationalinterviewing.org/
2. Psychosocial Recovery Model: https://www.psyrehab.ca/pages/principles-of-psr and https://psrrpscanada.com/
3. Tidal Model: http://www.tidal-model.com/ and http://www.nursing-theory.org/theories-and-models/barker-tidal-model-of-mental-health-recovery.php

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Learning to meet my patient where they are at - how letting go changed my practice

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