How motivational interviewing can enhance restorative supervision

Introduction

This article is the second in a series related to the professional nurse advocate (PNA) role. The first article – namely, Scanlon and Hart (2024) – described the value of PNA restorative clinical supervision (RCS) and the accumulating evidence supporting the positive impact of the PNA role on nursing professionals’ wellbeing, sickness levels and attrition as previously identified by Whatley et al (2021). Also outlined was NHS England’s (2023) Advocating and Educating for Quality Improvement (A-EQUIP) model, which profiles the PNA role by grouping the PNA’s supportive remit into four descriptors; all of which will inevitably have some overlap (Nash, 2021).

The A-EQUIP descriptors are:

• Formative – addresses supervisee educational development;
• Normative – seeks to promote monitoring and the managing of clinical competence and effectiveness;
• Personal action – focuses on enhancing quality improvement and assurance to benefit all staff and patients;
• Restorative – addresses the supportive aspect of the PNA role, which aims to improve stress management and mitigate burnout via PNA RCS. It is this focus on which this article is mainly centred.

The overall RCS goal is to compassionately encourage supervisees to develop deeper self-awareness and knowledge of self so they can draw on support from their colleagues and organisation to improve their coping skills and resilience. The ultimate outcome of RCS is that supported staff will feel empowered to advocate for quality improvements for themselves, their colleagues and their patients.

It is important to point out that the promotion of resilience is not the sole responsibility of an individual or a sole PNA, but a collective organisational responsibility, especially when staff are working in roles that are emotionally demanding and stressful (Maben and Bridges, 2020). As such, it is important to be aware that RCS seeks to support staff experiencing adversity by ensuring everybody plays a part in resolving difficulties in positive ways (Macdonald, 2019).

To successfully start facilitating workplace resilience via a conventional PNA-delivered, one-hour group or individual RCS session, the PNA must first provide their supervisee(s) with a safe psychological space in which to explore and reflect on their daily difficulties. To do this, the PNA needs to make sure their RCS has a focus on change by guiding them away from problem-focused talk, which reflects on daily challenges and difficulties, and towards solution finding and making plans for change by giving them the space to identify, acknowledge and process their issues (Miles, 2023). It is fair to say, from personal experience, that doing this can be challenging. It is, therefore, important that the PNA ensures their RCS is modelled on evidence and adopts evidenced communication strategies.

A way PNAs can ensure the focus remains on change is by structuring their RCS time using a recommended PNA RCS model such as Wallbank and Woods’ (2012) model of development of supervisees. This model details a three-step process, whereby the first step is to ensure the supervisee feels able to articulate and explore their anxieties and stressors. Importantly, psychological safety must be promoted for staff to voice their concerns (Rothwell et al, 2019).

RCS working agreements promote safety and cover key aspects such as confidentiality, timekeeping and the RCS aims. Working agreements can be detailed in employers’ PNA RCS policy documents, such as Anyika et al’s (2015) Policy for Restorative Clinical Supervision Programme, which is used by East London NHS Foundation Trust. In line with such agreements, the PNA may begin to facilitate a conversation focusing on supervisee anxieties. Once the supervisee is given an opportunity to talk over natural feelings related to their work, they are more likely to discover meaning in their experiences (Proctor, 2010).

The PNA may then progress to the second step of Wallbank and Woods’ (2012) model, which places an emphasis on resilience building and identifying solutions to articulated difficulties by identifying any learning or development needs.

Wallbank and Woods (2012) theorised that the positive talk that emanates from this has the potential to move to the model’s third step, which is to promote collaborative creative energy, whereby solutions to difficulties begin to be articulated and changes strategised or even operationalised.

Other ways the PNA may structure their one-to-one RCS sessions is to align the time and conversation to the structure of a nursing reflective model. One such model is that by Driscoll (2007), whereby following the reiteration of the working agreement, the start of the session emphasises exploring the experiences of the supervisee, then moves onto what can be learnt from any event described and what actions need to be taken to improve a situation.

Structuring RCS time using a model will strengthen the PNA’s RCS; however, for the PNA to successfully promote their recipients’ chances of identifying solutions and taking personal action to make positive changes in their working lives, the PNA must also harness exceptional interpersonal and communication skills (Adegboye et al, 2023). This article highlights:

• How motivational interviewing (MI) principles and communication methods partner well with PNA RCS practice;
• How they can strengthen and improve the quality of the PNA’s overall RCS.

MI has been defined as “a particular way of talking with people about change and growth to strengthen their own motivation and commitment” (Miller and Rollnick, 2023).

The evidence supporting MI’s application to RCS

There is a gap in the literature detailing explicitly how PNAs can strengthen their communication when conducting an RCS session. This is likely due to the newness of the PNA role. What the PNA literature does convey, however, is that the RCS model has been developed and underpinned by considering multiple leadership and psychological theories; one psychological intervention that has informed the RCS approach is MI (Foster, 2015). MI is an evidenced-based counselling approach informed by several seminal psychological change theories, such as:

• Reactance theory (Brehm, 1966);
• Self-perception theory (Bem, 1972);
• Self-determination theory (Deci and Ryan, 1985).

MI was originally developed in the field of addictions but is now promoted widely across many settings, including areas of practice that are piloting a blend of restorative and MI approaches, such as schools (Rollnick et al, 2016) and, after the Covid-19 pandemic, wellbeing support for health professionals (Endrejat and Kauffeld, 2021).

Adopting the MI spirit

It can be argued that MI marries well with the PNA RCS model for several reasons. A main reason is that the PNA’s RCS session, like MI, emphasises an interpersonal style or ‘spirit’ that is compassionate, conducted in partnership, accepting and promotes evocation, which – as a plethora of evidence highlights – leads to better change outcomes (Resnicow and McMaster, 2012). The PNA literature also points out that this interpersonal style promotes psychological safety (Carter, 2022; Wallbank, 2016).

Another key MI principle to emphasise to PNAs who are carrying out RCS is the importance of having a guiding style over a prescriptive telling style. The prescriptive approach – previously known as the ‘righting reflex’ – is now known in MI as the ‘fixing reflex’. It is important to resist this as not reverting to it leads to better change outcomes (Miller and Rollnick, 2023).

The principles of MI have intuitive or ‘common-sense’ appeal and core elements of MI can be readily applied to PNA RCS practice; however, the communication approach is not easy to learn (Miller and Rollnick, 2009).

Using OARS

A good interpersonal RCS communication style can be promoted by proactively using MI’s core communication skills, known by the mnemonic OARS, which are:

• Open-ended questions;
• Affirmations;
• Reflection;
• Summary.

Open-ended questions (O) seek in a gentle, accepting way to gain a better understanding of the supervisee’s problems, values and goals (Schumacher and Madson, 2014). This is opposed to closed or rhetorical questions that, often, demand a ‘yes’ or ‘no’ answer and do not get to the heart of a problem.

MI also promotes the use of affirmations (A). These are statements that highlight a person’s personal qualities and attributes. Affirmations are especially important when seeking to promote confidence, self-efficacy and self-esteem, and obtain more autonomous motivation (Markland et al, 2005); this is also an important PNA RCS goal (NHS England, 2023).

MI also places a strong emphasis on the use of reflective listening (R) and summary (S). Reflections sound back what has been heard. Summaries (S) are reviews of what has been heard, especially the need to change, as well as aspects of change that may be difficult and need more exploration.

Good facilitation of OARS should aim to be like a dance whereby, together, the OARS form the gliding dance steps.

Skilful advice giving

The PNA will also need to provide advice or offer signposting support at regular intervals during RCS. MI delineates how to give advice skilfully via the rule known by the acronym EPE:

• Elicit – before sharing some helpful information, the PNA must elicit (using OARS) what the supervisee already knows;
• Provide – the PNA will ask permission to provide the information. The information should only be conveyed after consent has been received from the supervisee;
• Elicit – once the information has been provided, the PNA may elicit once again (using OARS) the supervisee’s thoughts about that information.

The four tasks of MI

To ensure RCS focuses on change, the PNA may wish to consider Miller and Rollnick’s (2023) four tasks of MI (Fig 1). Although the diagram is presented in a linear-stepped form, people’s readiness to change fluctuates often, so the PNA needs to move from one task to another as appropriate. For example, the supervisee might be planning changes, then ambivalence creeps in and they begin to feel anxious about change. In this case, the PNA may feel it appropriate to focus on re-engaging with the supervisee.

Similarly to Wallbank’s (2013) group restorative model, an important attribute of MI engagement is the formulation of an understanding bond between supervisee and supervisor as, without this, change will not occur (Miller and Moyers, 2017). To convey engagement, empathy, active listening, congruency and genuineness must be evident. The literature related to PNA trauma, stress and burnout support highlights the importance of this engaging style (Miles, 2023).

The four tasks of MI emphasise the facilitator and supervisee identifying a change focus together. Addressing too many change focuses leads to poorer outcomes (Miller and Rollnick, 2023). For example, many anxieties may be voiced in a group PNA RCS session, whereby discussion, for instance, may revolve around staff feeling exhausted due to often missing breaks, leaving shifts late, cancelling non-urgent staff support meetings or not investing time in their professional development. The PNA may then work with the group to identify the change focus on which they might like to concentrate first.

When a focus is determined, the PNA may begin to evoke ‘change talk’ more proactively, whereby there is more potential for supervisees to identify creative solutions and plan actions. The MI communication methods the PNA may adopt to evoke change talk is firstly to listen carefully for any talk that suggests there is:

• Desire (D);
• Ability (A);
• Reason (R);
• Need (N);
• Commitment (C).

This is known as DARN (C).

When this change talk is heard, the PNA may respond to it by considering aspects of the mnemonic, EARS, namely:

• Evoking questions;
• Affirmation;
• Reflection, or;
• Summaries.

Examples of EARS being demonstrated in appropriate PNA responses to supervisee statements are as follows:

Statement: “I have already started to set time aside for my own professional development.”

Response: “Managing your time demonstrates great organisation and commitment” (A). “Tell me more
about your professional development plans” (E).

The PNA’s response acknowledges the supervisee’s talk of commitment (C), then gives an affirmation followed by an evoking open-ended question.

Statement: “I know I must sort my work-life balance out.”

Response: “You are very keen to get the balance right” (R). “Have you had any thoughts about how you might begin to do that?” (E).

The PNA’s response acknowledges the supervisee’s reason (R) or desire (D) change talk, and uses reflection (R) followed by an evoking question (E).

Addressing ambivalence

Change is naturally difficult and can be accompanied by ambivalence, whereby supervisees convey in their statements:

• Change talk – a wish to change;
• Sustain talk – a reluctance to change. Often, sustain talk is because the dynamics at play include, for example:
• High ambivalence;
• Low desire and importance;
• Minimal confidence.

Sometimes change can be tough for complex reasons that are difficult to articulate. It is, therefore, important for the PNA to strengthen their communication by responding to any ambivalence and sustain statements with OARS. The focus, however, should be on:

• Listening (L);
• Understanding (U);
• Resisting the urge to fix things (R);
• Empathising (E).

This is known by the mnemonic, LURE. Below are examples of appropriate PNA responses to supervisee sustain and ambivalence statements:

Statement: “I just can’t speak to my manager about my terrible shift pattern.”

Response: “Things sound difficult at present, tell me more why you feel this way?”and “Things must get better, but things will never change, we just can’t hold onto staff.”

The PNA’s response must acknowledge the sustain talk. An appropriate response might consider LURE – for example, a reflection followed by a question. It must also acknowledge the ambivalence statement and, importantly, the change talk in that. Another appropriate response might be a reflection, followed by a question, such as:

“The staffing issue is making change difficult, and change is needed” and “How could we start to improve things?”

Self-supervision

The PNA may strengthen their RCS communication via a process of self-supervision using the following checklist:

• Am I engaged? Are responses open and, intuitively, does communication feel comfortable?
• Is the focus right? Are we on the same hymn sheet?
• Am I hearing some change talk, ambivalence, or sustain talk, so I can begin to evoke change?
• Do I hear DARN (C) change talk? Can I begin to guide planning?

The PNA may also use the traffic-light tool shown in Fig 2. This ensures they do not jump ahead of their supervisee’s readiness for change, but guide their responses to each supervisee statement.

Conclusion

MI theory originally played a part in developing the PNA RCS process so it is not surprising that MI is closely aligned with the RCS delivery ethos, which places a strong emphasis on compassionate, engaging support that seeks to guide and encourage change in work practices and care delivery. The problem is that, as professionals supported by the PNA often face adversity in their daily roles, RCS sessions can be challenging – especially when staff are unable to move their focus from talking about problems to solutions. MI does, however, give the PNA well-evidenced guided communication skills that can address some of the complex psychological dynamics that often revolve around the aspects of change.

The intuitive or ‘common-sense’ appeal of MI’s principles means certain core elements apply to PNA RCS practice, yet mastering the communication approach is challenging. Employers need to invest in continued PNA MI educational development so PNAs can master MI and successfully apply it into their RCS practice. More formalised evaluations of PNA RCS practice would then be needed to explore MI’s impact on the RCS process.

• Part 3 of the series looks at how compassionate leadership can be applied to enhance the effectiveness of the professional nurse advocate.