John is a young man who is in A&E with a broken arm. Although it is likely that the arm will heal, John has had a serious accident. He is dehydrated and has a headache. When asked if he was drunk at the time of the accident, he becomes angry and questions whether it is any business of the nurse. The nurse tells him he has drunk too much and if he continues with the behaviour, he runs the risk both of becoming dependent and potentially involved in violent conflicts. John walks out of the department.
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1. How could the nurse better raise the issue of John's drinking?
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Correct answer:
The primary goal of MI is to resolve ambivalence and resistance and move a patient into a commitment to change their alcohol use so that John recognizes the advantages to drinking less while acknowledging the challenges for his social life. The nurse will have only limited time and may use the AUDIT alcohol screening tool to assess John's drinking behaviour.
To assess his readiness to change, the nurse may as part of a brief intervention, ask him to rate, on a scale of 1 to 10, "How important is it for you to change your drinking?" (with 1 being not important and 10 being very important).
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2. John is angry about being challenged. How can the nurse avoid this and encourage communication?
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Correct answer:
Motivation to change is elicited from the patient from within. It does not involve the use of external threats, scare tactics or risk communication. Encouraging change demands empathy, summarization, reflective listening, and other techniques. MI insists that patients take an active role in the decision to change their alcohol use, e.g. "Only you can decide to reduce your alcohol use. This is your decision. I am here to treat your medical problems and to hopefully prevent you from getting into trouble with your drinking. What do you think about agreeing to cut down for a month or two and seeing how it goes?"
