Title: Minimal improvement of nurses' motivational interviewing skills in routine diabetes care one year after training: a cluster randomized trial

Transcription

1 Author's response to reviews Title: Minimal improvement of nurses' motivational interviewing skills in routine diabetes care one year after training: a cluster randomized trial Authors: Renate Jansink (r.jansink@iq.umcn.nl) Jozé Braspenning (j.braspenning@iq.umcn.nl) Miranda Laurant (m.laurant@iq.umcn.nl) Ellen Keizer (e.keizer@iq.umcn.nl) Trudy van der Weijden (trudy.vanderweijden@hag.unimaas.nl) Glyn Elwyn (elwyng@cardiff.ac.uk) Richard Grol (r.grol@iq.umcn.nl) Version: 2 Date: 27 January 2013 Author's response to reviews: see over

2 POINT-TO-POINT REPLY Reviewer: Eileen Britt Major compulsory revisions General This paper evaluates the extent to which nurses apply motivational interviewing skills in routine care after brief training in motivational interviewing. Note the paper describes the training as "intensive" which is not accurate (see comment 3 below). It is recommended that the following is addressed before publication. 1. The authors have not considered other relevant research in this area, such as Brug et al and especially Britt and Blampied (2010) - there may be others papers which they have omitted as well - a comprehensive search of the literature is recommended and that these and any other relevant papers are considered in the introduction and discussion. We have added extra literature to the introduction and discussion. See reference list numbers: 13, 14, 16, 17, 18, 23, 26 and The definition and description of motivational interviewing is not consistent with the most recent definitive text on this subject - see Miller and Rollnick (2012). We adapted the definition and description of motivational interviewing to this most recent work of Miller and Rollnick. 3. The paper has not fully considered the implications of Miller et al which suggests significantly greater training time (as well as post training coaching) is needed for acquisition of motivational interviewing skills at a level that are exhibited post-training in routine care. Additionally there are other motivational interviewing training research papers which have not been included whose findings are important for this research. This research as a whole would suggest that it would be unrealistic to expect changes in the nurses motivational interviewing practice with the limited training provided in this study. As lifestyle education belonged already to the job of the general practice nurses, the size of the training was comparable to the study of Rubak et al. in general practice that showed a positive effect of MI on general practitioners professional behaviour [29]. A review of Madson et al. supported the idea that our number of MI training sessions was sufficient [38]. We have elaborated on this theme in the method and the discussion session (p.4/5 and p.10). The term intensive has been skipped due to the discussion on its exact meaning. 4. The conclusions in the comparison with existing literature section regarding lifestyle counselling and motivational interviewing sessions are too definitive, especially given above limitations of the current study. We completed the discussion according to this suggestion. 5. The paper needs to be carefully edited. We re-edited the paper. 1

3 Reviewer: Nicole De Zoysa Major compulsory revisions The critical remarks and hints of the reviewer helped us enormously to improve the paper, thank you very much. Abstract Conclusion paragraph 1.1 I think the conclusion needs to be less definitive. We don t know if the use of MI skills was hardly affected by the intensive training as a) the skills were not tested directly after training which may mean it was an issue of maintenance of skills rather than acquisition and b) we might question whether the training could be described as intensive given that the nurses received four half days of training over six months(which included other things as well as MI), no real life training caseload, a post training competency assessment with feedback. The fact that the nurses asked for an extra training session (THE STUDY, Intervention paragraph) might also support the idea that the training was not specific enough. I would suggest that the main conclusions should be centred on the maintenance of MI skills (as opposed to acquisition), what nurses actually do in a real life setting and the systemic issues around protected time. As suggested by the reviewer we changed the conclusion: The maintenance of the MI skills one year after the training program was minimal. The question whether the training could be described as intensive has been asked by the other reviewer as well (point 3). We skipped the term intensive and explained and discussed the length of our training program in more detail (see answer, point 3). Background 1.2 There is some literature missing regarding the efficacy of psychological approaches to diabetes care and efficacy of nurse delivery and training in MI e.g (in order of relevance) Maissi E, Ridge K, Treasure J, Chalder T, Roche S, Bartlett J, Schmidt U, Thomas S, Ismail K (2010). Nurse-led psychological interventions to improve diabetes control: Assessing competencies. Patient Education and Counselling 2011 Aug;84(2):e Used in background. Ismail K, Maissi E, Thomas S, Chalder T, Schmidt U, Bartlett J, Patel A, Dickens C, Creed F, Treasure J (2010). A randomised controlled trial of cognitive behaviour therapy and motivational interviewing for people with Type 1 diabetes mellitus with persistent sub-optimal glycaemic control: A Diabetes and Psychological Therapies study (ADaPT). Health Technology Assessment Report 2010; 14:1-10. Describes same study as Maissi Ismail K, Winkley,K, Rabe-Hesketh, S. Systematic review and meta-analysis of randomised controlled trials of psychological interventions to improve glycaemic control in patients with type 2 diabetes. Lancet 2004;363: Used in background. Winkley K, Landau S, Eisler I, Ismail K. Psychological interventions to improve glycaemic control in patients with type 1 diabetes: systematic review and meta-analysis of randomised controlled trials. British Medical Journal 2006;333:65. Used in discussion. Ridge K, Forbes A, Thomas S, Treasure J, Ismail K. Themes elicited during motivational interviewing to improve glycaemic control in adults with type 1 diabetes mellitus. Diabetic Medicine 2012 Jan:29(1): doi: /j x. (for Discussion) Used in discussion. Results The reviewer didn t use the numbers 2.1 and 2.2 in the final report. Study population paragraph nurses were trained, while we invited the 35 nurses in the control group The numbers here are different to the numbers cited in the Abstract. We changed the numbers in the Abstract. The right sentence is 30 nurses were trained, while we invited the 35 nurses in the control group. 2

4 We reworded the paper according to the following suggestions. Improvement of MI skills paragraph 2.4 I think this section needs to be more carefully worded to avoid it being misleading. I would suggest rephrasing as follows, Table 2 shows that nurses only showed a significant improvement in 2 of the MI skills at one year follow up compared to baseline. 2.5 Use of the word post in post measurement mentioned both in this paragraph and the table could be misleading in inferring immediate evaluation of the training as opposed to one year follow up. I would suggest rephrasing as one year follow up throughout the paper. Discussion We added a paragraph in the Discussion; Separate MI sessions. First paragraph 3.1 I would suggest taking out intensive in the first sentence as misleading see point above (1.1) and rephrasing as follows, The MI training embedded in a comprehensive program to improve routine diabetes care in general practice had a minimal impact upon lifestyle counseling practice of MI skills when assessed at one year follow up Strengths and limitations of this study 3.2 Suggest rephrasing as, Based on this feedback, we assumed that being highly selective of taped consultations was not feasible. This endorses our results that the intervention had a minimal impact upon MI skill in routine diabetes care. To address language issues in the first sentence and clarity of conclusions in the second sentence. Comparison with existing literature paragraph We changed the title of this paragraph to MI skills at one-year follow-up. 3.4 Compare results with reference below, re. acquisition of MI skills. We compared our results with Maissi et al as suggested, see Lacking lifestyle counselling skills paragraph. 3.5 I would suggest extending the following sentence as follows, to imply that the consultation structure might need to change rather than the MI. MI seems to be unsuitable for routine diabetes care consultations in their current format. We removed this sentence. Lacking lifestyle counselling skills paragraph 3.4 However, the nurses expressed almost no improvement on the MI skills during practice I think this is misleading, because we do not have a post training measure. I would rephrase as, However, the nurses showed little change in MI skills when assessed at one year follow up I was unsure what was meant by the following sentence, please could the authors clarify, But we should also consider that the nurses only indicate that they have good interviewing techniques when patients have changed their lifestyle behaviour. We removed this sentence. Diabetes care and MI paragraph I would suggest rephrasing penultimate sentence as, Since the MI skills showed minimal improvement at one year follow up to emphasise this is maintenance rather than acquisition. 3.6 There are reports of HbA1c, blood pressure etc. but no mention of this in the methods or results section. We added the reference of our study protocol [28] to the background paragraph as well as the paragraph study design and population. Reports of HbA1c, blood pressure etc. have been described in a separate paper for the Scandinavian Journal of Primary Health Care (revised version submitted October 2012). 3.7 I m unsure what the 34.5% and 34% are actually referring to. Could the authors clarify. We decided to take this information out of the paper, because the information contributes too little to the main message. A more detailed description of this figures has been given elsewhere (see 3.6). 3.8 There is a report of similar target HbA1cs in both groups, but the reader would need to know if contact time (with the patients) between the groups was also comparable. 3

5 The mean duration of consultation differed significantly between intervention (21.8 minutes) and control group (17.6 minutes). We added this information in the consultation characteristics section (p.8). Conclusion 3.9 First sentence, change hardly improved to showed minimal improvement after MI training embedded in. and remove intensive training. We rephrased the sentence as suggested. 4.0 I would change hardly improved to showed minimal improvement in the first sentence. See also point Last sentence, should include the role of nurse support/supervision as another potential barrier to success in implementing MI. We included the potential barrier of the role of nurse in implementing MI (p.11). Minor revisions Title 5.1 Consider changing the title of the paper does not flow grammatically. We changed the title into Minimal improvement of nurses motivational interviewing skills in routine diabetes care one year after training: a cluster controlled trial. We reworded the paper according to the following suggestions. Abstract First paragraph 6.1 The words diabetes and general practice should be included to make it clear to the reader which population is being studied. Consider rewriting as follows, The current study compared MI skills of trained versus non-trained general practice nurses in diabetes consultations. Results paragraph 6.2 I think the first sentence is misleading as MI skills were not tested immediately after the course. It may be more accurate to rephrase as At one year follow up, it was demonstrated that the nurses improved on 2 of the 24 MI skills Background Second paragraph 7.1 I would suggest calling the additional MI tools mentioned as techniques (rather than principles) and take out the reference to disagreement. i.e Also agenda setting, scaling questions, and assessing importance and confidence in changing lifestyle can be used as techniques to support MI.. Fourth paragraph 7.2 Take out the before usage so it reads as, Information about the extent to which nurses apply MI skills and the factors that affect usage can help to 7.3 Last sentence consider replacing indecisive with mixed. Fifth paragraph 7.4 s missing after characteristic. In addition, the influence of consultation characteristics The Study Study design and population paragraph 8.1 I would suggest rephrasing first sentence as follows for clarity. Nurses working in general practice were recruited for a cluster randomized controlled trial in the south eastern part of the Netherlands. 8.2 It would be useful to know if this was mainly a rural, urban or mixed area. We indicated in the paper that it included rural and urban general practices. Measures and data collection paragraph 8.3 I was unclear as to whether the five video recordings were of different patients or different consultations with the same patient. And whether these patients were part of the study or before the study started? Could the authors clarify? 4

6 The word successive has been skipped. The paragraph was rephrased as follows. The nurses made video recordings of five type 2 diabetes consultations with different patients during the months February to May 2007 (baseline). The patients had to give consent for the recordings and its usage in the study. The recordings had to have clear sound. If video recordings failed, audio recordings were accepted. Nurses, who did not respond, were repeatedly reminded by and telephone until the program started. All nurses were asked to record again five videos of diabetes consultations after roughly a year (14 months) during the months April to September I would suggest changing non responders to Nurses who did not respond. 8.5 As well as nurse ratings, I think this section also needs to explain how readiness to change of the patient was assessed from the video recordings. The judges assessed the patients readiness to change, by means of a predetermined scoring list. We added this information to the paper (p.6). Data analysis paragraph 8.6 I suggest changing Cronbach s alpha was regarded to used if that was what was meant. Results Study population section 9.1 First sentence, second paragraph take out a practice assistant, so it reads, The control group had significantly more experience as practice assistants than 9.2 Take out these practice assistants and s from years so it reads, Since 1999, practice assistants can follow a 2 year training Consultation characteristics paragraph 9.3 Suggest rephrasing to, and when more time was spent discussing lifestyle factors Discussion First paragraph 10.1 Insert comma to read as, The comparison of video consultations in a cluster randomised controlled trial showed that two of the 24 skills improved, that is Comparison with existing literature 10.2 For language clarity I would suggest rephrasing the last sentence as, It may be more successful to arrange separate MI sessions with sufficient time for lifestyle counselling. Lacking lifestyle counselling skills 10.3 For clarity, I would suggest rephrasing as, In the curriculum, interviewing techniques are addressed but not specific to MI. Consequently, the nurses who participated Diabetes care and MI paragraph 10.4 For language clarity, I would suggest rephrasing the last sentence as follows, It seems important to have more studies reporting on MI skills observed in clinical practice. Discretionary revisions General 11.5 Consider taking out the use of we throughout the manuscript. We took out we throughout the manuscript. Results Consultation characteristics paragraph 11.6 Can the authors give an indication of how long consultations were? We have added this information, see