the art and science of conversation in dietetics
TRANSCRIPT
Journal of Critical DieteticsISSN 1923-1237
Vol 3, Issue 1Copyright 2016
Toronto, ON
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REFLEXIVE WRITING
The Art and Science of Conversation in DieteticsChristine McIntosh MS RD
Department of Graduate Studies, PhD Sustainable Education, Nipissing University, North Bay, Ontario, Canada
IntroductionConversation is referred to as an art. Therapeutic
conversation is grounded in the science of psychology.
Consider, then, the art and science of patient-
practitioner conversation in healthcare. What would a
helpful and healing conversation sound like? How would it make one feel?
I felt it. I was in a course for motivational interviewing
(MI) training and during a counseling skill paired activity
I told my partner about a patient situation. I knew
she was listening because she smiled encouragingly
when I hesitated, paused to let me think, leaned in
andgenuinely said, “Tell me more.” So I did and when
finished, I felt better about the situation, and I had a solution to my concern. That was my first experience of the MI process to conversation. Today I can give an
academic explanation of the skills that were used in that interchange, but it is this memory that resonates as I
move forward in my profession.
Motivational interviewing involves an interviewee and
interviewer. It is grounded in a creative flow of intentional transparency and dialogue designed to motivate a patient
in decision and action toward their own determined
goals. The questions asked are meant to acknowledge
and validate the person’s concerns, offer alternatives,
and assist them to a new self-determined action plan.
It is a collaborative conversation that strengthens a
person’s commitment to behavior change.
Over a period of thirty years, Miller and Rollnick
(2013) observed and developed an MI model that is
characterized by seven unique but overlapping defining
features which include: autonomy, collaboration,
evocation, rolling with resistance, expression of empathy, development of discrepancy, and support of self-efficacy (Hollis, 2014). These characteristics are exemplified in the dietetic scenario presented throughout this paper.
Dietitians using MI are relatively low in number
worldwide, but the application and impact of MI on
patient outcomes has a good record to date (Williams,
Hollis, Collins, and Morgan, 2014; Hollis, 2014). It is a
skill-set, and like art, it is intuitive, but it requires good
technique like a craft; further, it is substantiated by
research and grounded in compassion. The following
scripted scenario, with explicitly labeled technique, is included to illustrate the craft while evoking an inner
dialogue with you, as the reader. The conversation will
continue, pausing at critical moments to offer a theory
into practice reflection on the MI features presented and punctuated by sage advice stated by Miller and
Rollnick (2013). The intention of this style is threefold:
to allow the reader to identify their practice with the
conversation; to “hear” the conversational technique
in the script; and gain insight by the interrupting wise
words of Miller and Rollnick (2013).
Autonomy and Collaboration Conversations in healthcare have the intention of
eliciting information from the client. If considered from
a therapeutic perspective, there also needs to be a
relationship from which to assist the client. In MI, the
art of conversation is to build a trusting foundation
from which the practitioner can relay the need for
teamwork. The client does need to also understand
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that the conversation will lead to a point of individual
decision. This necessitates both client autonomy and
collaboration.
Christine: Last time we got together, we talked a lot and got to know each other. You made decisions for change about this and that. How did it go? [open-ended question to build collaboration]
Sal: It did not work so well. Can you give me a meal plan?
Christine: I am curious about what did not work. Hmm. I could give you a meal plan…. what if we talk about what happened with your plan and see what we else we can do together? [affirmation of situation and support of autonomy]
Sal: I am tired of trying.
Christine: It sounds like this is hard for you right now. [affirming emotion, supportive, and leaving open-ended option for patient to offer more information and not offering advice]
Sal: It is hard. I just want to have this change now.
[Christine resists providing advice in order to follow the first aspect of MI – autonomy. The goal is to have Sal make the change and not rely on Christine’s directives]
“An open ended question is like an open door”
(Miller & Rollnick, 2013, p. 62).
The beginning of rapport building sets the tone for
further conversation. If the counselor can refrain from
providing a solution for the client from the beginning,
the stage is set for the pending hard work of client
identification of their barriers to change.
Dietitians are entering a new world of healthcare, that of
increasing levels of patient self-care and self-management.
The dietitian is in the spotlight, an important member of
the healthcare team who has a role in assisting patients
to make right choices. Here lies the issue. Dietitians are
very well trained to be educators. Our training is part of
the larger medical model designed to treat and fix acute health problems, but the demographics of an aging
population and the impact of lifestyle related diseases
has altered health services requirements (Hanna, 2010;
Health Council Canada, 2011). In an acute model of
care, dietitians traditionally provide education to inform
patients about their choices and provide leading options
for expected dietary compliance (Hollis, 2014). The diet, then, is provided like any treatment: obey the directive
and health will improve. Chronic diseases by definition are not curable, do require medical treatments, but are
largely managed on a daily basis by the patient (Hanna,
2010; Health Council Canada, 2011). This change in
disease type necessitates a change in educational
approach (Hollis, 2014). Where much of modern disease
management requires self-care, health education needs
to inspire and motivate rather than direct and govern.
Evocation
Christine: We can work towards change. Do you have thoughts about this? [supporting autonomy]
Sal: Why can’t I just take a pill to fix it?
Christine: We can talk about making an appointment for medications with the Nurse Practitioner. Maybe talking about the plan is not the right thing right now. I remember you mentioned this or that alternative last time. What other things have you thought about? [supporting autonomy by asking/reflecting/affirming and at the same listening for words that contain the concepts of change talk such as might, maybe, I guess I could, etc. The goal is to evoke a desire to consider change]
“It is when people experience acceptance of themselves as they are that change is possible”
(Miller & Rollnick, 2013, p. 246).
In this climate of health change, it is not only the
patient who is challenged to change habits. Dietitians,
themselves, may feel this need for change, and ask
themselves, “Is there a quick fix for my counseling frustration?”
When MI became part of my professional repertoire,
I knew that I had found a solution to my professional
frustrations. The fact that counseling skills had
not been part of my training left me wondering if
counseling was an expectation with dietetic scope of practice. I consulted a study by Hollis et al. (2014)
who had conducted a literature review to look at
dietitian professional standards in Australia, Canada,
New Zealand and the United States to assess the value and inclusion of counselling skills. Much to my
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surprise, the findings demonstrated that the concepts of counselling are included in the elements of practice
in all four countries. Further the findings by futurists who project the nature of dietitian work in the USA as far as the year 2020 indicates that it is highly likely that
more patients will be seeking lifestyle change counseling
in years to come (Rhea & Bettles, 2012). Increasingly,
dietitians will need to work with food industry trends
such as the production of healthier foods and increased
chronic disease and obesity (Rhea & Bettles, 2012).
Dietitians want to affect patient outcomes; it is our
professional motivation. But we need to consider the
traditions of our discipline. Williams (2002), in his study of
Self Determination Theory, applied it to the education of
healthcare professionals and concluded that an attitude
is taught by example. The diagram (Figure 1) shows that autonomy is acquired by the student health professional
when modelled by the instructor. A person’s value of
autonomous decision making is then cast into their
future career (Williams, 2002). To build on this – where the health educator is taught in non-didactic ways when
as a student, they are primed to support patient self-
determination later in practice.
Figure 1. Illustration of how autonomy is taught in school. Adapted from “Improving Patients Health Through Supporting the Autonomy of Patients and Providers,” by G.C. Williams, 2002,Handbook of Self Determination Research, p. 249. Copyright 2002 by the University of Rochester Press.
Support of patient self-management is rooted in a
commitment to patient autonomy (Williams, 2002).
This shows that Self Determination Theory captures the
spirit of Motivational Interviewing (Miller, 2013).
Rolling with Resistance
Sal: Why do you ask so many questions? I am here for answers. Just tell me what to do!
Christine: [smiles and pauses] I could tell you what others with similar situations have done to reach their goals. [supporting autonomy, avoiding being pushed, offering another suggestion]
“If the client is raising the problems and you’re
providing the answers, you’re in the wrong chair
(Miller and Rollnick, 2013 p. 273).
Dietitians need to be committed to supporting patients,
as suggested by Williams (2002) (see Figure 2). When
the health provider and patient are matched in their
commitment to autonomy, it is more likely that the
patient will achieve their health goals. Patients can
change with or without the provider, but often the
impetus for patient motivation rests with a committed
provider.
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Figure 2. Illustration of how autonomy is taught by autonomously trained health providers. Adapted from “Improving Patients’ Health Through Supporting the Autonomy of Patients and Providers,” by G.C. Williams, 2002, Handbook of Self Determination Research, p. 240. Copyright 2002 by the University of Rochester Press.
Dietitians’ motivation to alter ways of communicating
with patients certainly evokes a desire towards different
ways of practice. But change is difficult.
Both clinical experience and the literature show that professional burnout often result when ideals are
not congruent with work reality (Yuka, de Jonge, Katz,
& Gingras, 2012). Who motivates the clinician? Dietitians are taught to process efficiently, follow guidelines, chart success, and move on to the next task. But therapeutic conversations are not always linear and do require time
(Miller & Rollnick, 2013). Studies show that dietitians
stay in the profession and get past their frustrations
because they find resilience built on passion, ideals, supportive relationships and opportunities for change
(Yuka et al., 2012). They develop their art of motivation
to keep themselves engaged in their work while
wondering if there is a better way to assist patients to
make health changes.
Expression of Empathy and the Development of Discrepancy
Sal: Yes. Tell me. I have to change this but I don’t have time.
Christine: You have other things going on in your life, like they did. Let me tell you about so-and-so…[offering empathy and choices]
Christine continues: I hear you say there is urgency to make the change and on the other hand it is not the right time for you to do this. [developing discrepancy]
Sal: Yeah. I guess I am just avoiding the fact that I need to change.
“All change is self- change, to which clinicians are
sometimes privileged witnesses and facilitators”
(Miller & Rollnick, 2013, p. 296).
A discrepancy between a habit and a desire creates
a tension that needs to be solved for the behavior
to change, often referred to as ambivalence (Miller
& Rollnick, 2013). When the dietitian on one hand,
feels unsuccessful in counseling, and on the other
hand, anticipates difficulty to change her practice but resolves the discrepancy, she can capture the internal
motivation to move forward. MI offers this solution.
But MI is a complex skill that is not learned overnight. Miller (2013) recognizes that the skills seem intuitive
but effective application takes continued effort. He
jests that patients receive no harm from poorly applied
skills but practitioners harm themselves when they are
self-deceived into thinking that they are more effective
than they really are. Competence occurs with reflective practice (Hollis, 2014; Hollis et al, 2014; Miller, 2013).
Support of Self Efficacy
Christine: What do you know about your past successes that would apply to this situation? [finding success in past experience]
Sal: Oh! I stopped this and that back in 1999. I guess I
could try that again. [client speaks change talk]
Christine: That is a good idea. Tell me how you can do
that…[Christine continues to ask open ended questions
for continued dialogue and resists providing strategies
that has seen work for others in the past.]
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“When techniques become tools to use on people,
one has abandoned the spirit of MI.” (Miller &
Rollnick, 2013, p. 315)
The art of MI is founded in the philosophy of putting
the other first. The dietitian must be willing to maintain a critical and reflexive stance. This refers to an internal query and a wide external review of the conditions affecting practice (Kinsella, 2013). MI requires a
disposition toward reflexivity suggesting the importance of practitioners maintaining a big picture view while in
conversation. MI demands the practitioner to call out
the discrepancy that blocks the patient from moving
towards decisive action but lays down no judgement.
The practitioner supports the patient’s self-efficacy while remaining independent of the patient. MI is
midway between directing and following – it is guiding (Miller & Rollnick, 2013). In the same way dietitians’
reflexive practice leads their professional choices through a socially informed, critical assessment of their
impact upon their sphere of influence (Kinsella, 2013).
The art and science of dietetic communication is found
in what dietitians say to patients and to themselves.
Therapeutic conversation skills found in MI can move the
dietitian to competence in assisting patient change, while
the internal reflexive conversations moves the dietitian forward in professional development. As the health
issue of chronic disease self- management has been
about patient motivation, the profession of dietetics has
started to embrace the skills of MI. Courses and training
can be found on national dietetics websites and within
regional health programs in many countries today. There
are many challenges that face this trend and the least
of these is the skills development required. If health
professionals are to borrow skill sets from psychology,
then training has to ensure expertise. The risk of adding more skills expectation to an established professional such as dietetics is there may not be universal will to
ensure quality assurance. Critical Dietetics stands for
sustained changes in dietetics practice and collaboration
with allied health fields in order to encourage different ways of thinking (Dietitians of Canada, 2009). The
embracing of counseling expertise is plausible for professional development but what of other counseling
strategies? A consideration of other techniques is pertinent in order to consider how to meet the needs
of clients.
The art and science of dietetics communication will
necessarily include various ways to interrelate and
encourage client behaviour change. MI encompasses
a skillset that works well with people who feel stuck
in a health defying behaviour, and assuredly, dietitians
often work with highly motivated clients where
health coaching or problem solving may be a better
communication choice. The attraction of MI to me is
that is involves the professional and personal self as
much as the client. With self support of professional
development in collaboration with clients, allowance of
an evocation to change of practice, ability to roll with my
resistance, patience with inconsistancies in my practice
and continued search for the best practice methods
(Hollis, 2014), I have applied MI to myself. This change
of practice works to advance patient self-care. Change
is in the air; I can feel it.
ReferencesDietitians of Canada (2009). Critical Dietetics: A Declaration
June 2009. Practice: exploring members’ practice
issue, 48(Winter), 1-2. Retrieved from http://www.
criticaldietetics.org/PDF/CriticalDieteticsDeclaration.pdf
Hanna, A. (2010). Patient centered care: a policy paper.
Ontario Medical Review, June, 34-39. Retrieved from https://
www.oma.org/resources/documents/patient-centredcare,
2010.pdf
Health Council of Canada Council, Health Council of Canada.
(2012). Self management support for Canadians with
chronic health conditions: A focus on primary health
care: Retrieved from http:/www.healthcouncilcanada.ca_
detphp?id=372Hollis, J. (2014). Dietary intake and physical activity behaviour
change for weight gain prevention in mid-age Australian
women (Doctoral thesis, University of Newcastle, Callaghan, Australia). Retrieved from http://hdl.handle.
net/1959.13/1045004
Hollis, J. L., Williams, L. T., Collins, C. E., & Morgan, P. J.
(2014). Does motivational interviewing align with scope
of practice, professional competency standards, and best
practices guidelines in dietetics practice? Journal of the
Academy of Nutrition and Dietetics, 114(5), 676-687. doi:
10.1016/j.jand.2013.12.023
Kinsella, E. A., & A. Pitman (Eds.). (2013). Phronesis as
professional knowledge: practical wisdom in the professions.
Rotterdam, NL: Sense Publishing.
Marley, S. C., Carbonneau, K., Lockner, D., Kibbe, D., &
Trowbridge, F. (2011). Motivational interviewing skills are
positively associated with nutritionist self-efficacy. Journal of
Nutrition Education and Behavior, 43(1), 28-34. doi:10.1016/j.
jneb.2009.10.009
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Miller, W. (2013). Confessions of a recovering trainer: what
about decisional balance? Motivational Interviewing: Training,
Research, Implementation, Practice, 1(2), 2-5.
doi: 10.5195/mitrip.2013.30.
Miller, W. R., & Rollnick, S. (2013). Motivational interviewing:
helping people change (3rd ed.). New York, NY: The
Guilford Press.
Rhea, M., & Bettles, C. (2012). Future changes driving dietetics
workforce supply and demand: future scan 2012-2022.
Journal of the Academy of Nutrition and Dietetics, 112(suppl
1), S10-24.
Williams, L., Hollis, J. L., Collins, C. E., & Morgan, P. J. (2014).
Can a relatively low-intensity intervention by health
professionals prevent weight gain in mid-age women? 12-Month outcomes of the 40-Something randomised
controlled trial. Nutrition & Diabetes, 4(5), e116.
doi: 10.1038/nutd.2014.12
Williams, G. C. (2002). Improving patients’ health through
supporting the autonomy of patients and providers. In E., L.,
Deci, & M., R., Ryan (Eds.), Handbook of Self Determination
Research (pp. 231-254). Rochester, NY: University of Rochester Press.
Yuka, A., de Jonge, L., Katz, L., Gingras, J. (2012). Meanings
of burnout and resilience in Ontario dietitians. Journal
of Critical Dietetics, 1(2), 13-20. Retrieved from http://
cr iticaldietetics .r yerson.ca/index.php/cr iticaldietetics/article/view/
Author BiographyAs a dietitian with diverse interests over many years,
Christine’s publications include co-authorship of
FoodAction: manual for agency and community
development (1987) and contributory writing for World
Vision Canada MICAH Report (1999) and Nutrition
Marketplace (2010). Current work as a senior teaching
fellow at Bond University, Queensland, Australia led to a paper presentation at Dietitians of Canada Conference
June 2015, Student dietitians: empowered for change,
a case review of how motivational interviewing is
taught to students. Longevity in the profession has led
Christine to a thesis study on the topic of motivational
interviewing in dietetics that is presented in this article.