FROM INPATIENT to outpatient to community nursing, health promotion and patient education are core nursing interventions. Motivational interviewing (MI) is a clinical communication skill that nurses can develop to elicit patients' personal motivations for changing behavior to promote health. Nurses can then emphasize these factors in their teaching to help patients modify their behavior.1
The spirit of MI entails a collaborative partnership between patients and nurses. With MI, nurses can explore patients' understanding, motivation, confidence, and roadblocks to change by asking evocative questions, acknowledging patient autonomy and personal responsibility, and reserving judgment. This article familiarizes nurses with MI principles and communication techniques that can be implemented across many settings.
Originally designed to help people with addiction change unhealthy behaviors, MI research has broadened to include behavior change associated with medication adherence, dietary changes, smoking cessation, and physical activity.2 For example, a 2010 randomized control trial involving 250 patients with type 2 diabetes who received MI demonstrated significant improvement in self-management, self-efficacy, quality of life, and A1c control compared with patients receiving usual care.3
A recent study assessing nurse competency indicates that nurses in various specialty areas and at many educational levels can become competent in psychological interventions such as MI to improve patient health outcomes.2 When used effectively, MI may improve patient outcomes in diverse areas such as medical-surgical units, ICUs, oncology units, EDs, and home healthcare.
Today's focus on preventive medicine and self-care makes it even more critical that nurses not only provide information but also facilitate change. MI is a vehicle for mapping out a personal plan for behavior change based on patient preferences and priorities.
Make it a conversation
MI needn't entail formal hour-long sessions. Instead, nurses can pose carefully selected questions, actively listen to their patients' responses, and engage patients in a conversation that highlights where they are now and where they want to be in the future. These techniques can be used in 5- to 10-minute increments throughout the day as nurses care for their patients.4,5 (See Using OARS to propel MI.)
MI moves patient education and discharge planning beyond nurse-driven information sessions. Authoritarian advice-giving discounts a patient's preferences and opinions about the feasibility of implementing change. Evidence shows that a more patient-centered approach produces better outcomes than an authoritarian approach.6,7 MI elicits patients' present concerns, helps them become aware of their ambivalence about their behaviors, and motivates them to make behavioral change. Rather than following the counselor's direction, it emphasizes the patient's perspective and autonomy.7 The patient-centered focus encourages patients to explore their priorities, motivations, and resources and to engage in problem solving and goal setting for quality health outcomes.
The goal of MI is straightforward: break down overwhelming behavioral change into manageable tasks to give patients the confidence to carry out treatment recommendations step-by-step. To illustrate, consider this case study.
Meet the patient
Mr. T, 59, has been admitted to the medical-surgical unit with severe hyperglycemia for the third time in the last 9 months. He was diagnosed with type 2 diabetes mellitus when he was 43 and started using subcutaneous insulin 2 years ago. He's joined formal diabetes management groups at his wife's insistence. He's had nutritional counseling and diabetes education but complains about the diabetes diet he's been prescribed in the hospital. Although he's demonstrated correct insulin self-administration technique for his nurse, his medication regimen adherence is questionable.
Mr. T's body mass index is 32.8, indicating obesity. His health history includes gallbladder disease and cholecystectomy. Current assessment findings include temperature, 98.4° F (36.9° C); pulse, 92; respirations, 18; BP, 152/86; SpO2, 98% on room air; and, at 0600 hours, fasting blood glucose level of 270 mg/dL.
How should nurses approach this patient to help him make wise decisions to improve his health? By first exploring the principles of MI presented here, nurses can be prepared to use MI to motivate this patient and others like him to take steps to improve their overall health.
Roadmap to MI
MI follows these general principles:7
* Express empathy. Use reflective listening to convey acceptance and a nonjudgmental attitude. This technique, which involves rephrasing the patient's comments to reflect understanding, conveys that the nurse is listening and trying to understand the patient's point of view.
* Highlight discrepancies. Helping patients become aware of the gap between their current behaviors and their goals is more likely to motivate them to change their behavior then telling them what to do.
* Roll with resistance. Adjusting to resistance is better than arguing directly for changes. Accepting patient ambivalence is part of the process.
* Support self-efficacy. Encourage patients' optimistic belief in the prospect of change. This encourages them to commit to positive behavioral changes.
Two MI principles, expressing empathy and supporting self-efficacy, are well known to nurses and should be incorporated into all therapeutic communication techniques as a mainstay of nursing practice. In most healthcare settings, nurses benefit by receiving report before meeting their patients. Sometimes they also form preliminary opinions of their patients. At this point, nurses must stop and evaluate their biases.
For example, nurses may be frustrated that this is Mr. T's third admission for hyperglycemia or that he hasn't adhered to outpatient treatment. Has his nurse written him off as a lost cause, or judged him for not making the recommended dietary modifications and losing weight?
Effective MI requires that nurses meet patients where they are.2 Change is hard; nurses shouldn't challenge patients' resistance to it. Highlighting past successes, no matter how small, raises patients' confidence and supports self-efficacy. Empathy, a fundamental nursing value, is paramount to establishing the necessary rapport.
Engaging patients in an MI-flavored conversation involves tapping into a few principles designed to help them elicit their own motivation and an achievable plan for treatment adherence. Guiding principles of MI are as follows:4
* Resist the righting reflex. Nurses have an innate instinct to offer a solution to “right” the problem.4 Nurses should avoid imposing their own perspective on the process.
* Understand patients' motivations. Nurses should try to uncover patients' own reasons for making behavioral changes.
* Listen to patients. Learning about their perspective on behavioral changes is critical.
* Empower them. Nurses can support patients as they investigate ways to change behaviors.
Most of the principles are easy enough to implement, but many nurses have trouble resisting the righting reflex. For instance, if a nurse hears that Mr. T usually spends his day either sitting at a desk or watching TV, the nurse might be tempted to explain the benefit of exercise to him. Instead of offering a solution, however, the nurse should try to guide Mr. T to problem solve and reach his own solution so that it's both important and manageable for him. This solution may be different from what the nurse would do; that's perfectly all right as long as patients' actions aren't harmful and don't contradict the goal.
In the same vein, another general principle of MI, rolling with resistance, requires nurses to resist the urge to take a confrontational stance.4 Arguing in favor of change naturally places the patient on the defensive and in a position of arguing against change—the opposite of the intended goal. This is the time to exercise acceptance and let the patient work through his or her ambivalence without assuming an authoritarian stance.
Assessing readiness for change
The Transtheoretical Model, a framework of health behavior change, suggests that people move fluidly, not necessarily in a linear fashion, through five different stages of behavior change.8 (See Identifying the patient's stage of change.) Determining how open a patient is to making changes is key to providing appropriate support when collaboratively developing a plan, with the nurse guiding the process based on patient preferences. For example, just developing a detailed plan to eliminate refined carbohydrates, stop smoking, or get 60 minutes of daily exercise can overwhelm patients in the contemplation stage. For patients who aren't yet considering making any changes—those in the precontemplation stage—it's a waste of time. What they need are motivation and confidence to move forward from wherever they are in the change process. Otherwise, they're being set up for failure.
MI is particularly useful for people who are ambivalent about making change—those in the contemplation stage. Although they may recognize the need, they aren't sure that the pros outweigh the cons.
How do you identify someone who's ambivalent about following a treatment recommendation? Listen for the “yes, but....” The “but” in the middle is the key that opens the door to a conversation about ambivalence, the first step in moving toward behavior change.
* “I know I need to lose weight, but I just love sweets.”
* “I want to take my medication, but I hate the way it makes me sleepy.”
* “I need to start exercising, but I can't seem to find the time.”
Everything after the “but” reveals patients' personal roadblock to meeting their goal and should be taken into consideration when planning treatment to improve the likelihood of adherence.
Similarly, listening for clues, or “change talk,” in the conversation lets nurses know patients are moving toward readiness for concrete treatment planning. Change talk includes phrases that indicate some level of commitment to making a behavior change. These phrases may:
* express desire (“I want to...”)
* ability (“I can...”)
* reasons to change (“I want...”)
* need (“I have to...”).
Goal setting is an important collaborative task that should begin early in the admission rather than on the day of discharge. Goals should be specific, measurable, attainable, time dependent, and relevant to the patient. When many lifestyle changes are in order, help patients prioritize what they want to work on first.
During the conversation, nurses should identify discrepancies between patients' goals and values and their current behaviors. Patients should be presented with objective information that highlights the consequences of continuing the status quo compared with the potential advantages of implementing change. Goal setting is also an opportunity to find out what patients already know about their disease, clarify misconceptions, and provide some health teaching. See how the nurse puts this into practice with Mr. T:
Nurse: “Mr. T, what's your understanding of the complications of diabetes?”
Mr. T: “I guess it can cause blindness and kidney failure in the long run. I know a guy who had his toes amputated because of diabetes.”
Nurse: “How likely do you think those things are to happen to you?”
Mr. T: “I didn't really think about it before, but I guess I'm more vulnerable than I thought. I don't want to be in and out of hospitals or tied to a dialysis machine for the rest of my life.”
Nurse: “How do you think you can avoid those things?”
Mr. T: “I'm going to have to keep my blood sugars in check and start watching what I eat.”
Mr. T's choice of words—“I'm going to have to...”—is an example of change talk in which he indicates his readiness to make a change.
Reflective listening is an important skill that encourages patients to further elaborate and explore their ambivalence. It demonstrates that nurses are trying to understand patients' points of view, and lets patients know they're being heard and accepted. Patients who feel “heard” tend to overestimate the amount of time they spend with the healthcare provider; patients are more likely to be open and honest and tend to be more satisfied with their care.6
A simple reflection involves rephrasing what was just said. If nurses are correct in their interpretation, patients will then elaborate. If nurses are wrong, patients will clarify and then elaborate.
Rating scales, commonly used to assess pain intensity levels, can be adapted to evaluate confidence and readiness for change. When patients are asked to quantify their readiness or confidence on a scale of 0 to 10, with 0 meaning not confident at all and 10 meaning most confident, they have to quickly weigh all sides and come up with a concrete answer. By asking them why they didn't choose a score that's 2 less than the one they've chosen, nurses can guide them into positive self-talk, and patients hear themselves arguing in favor of change. Asking patients to elaborate on past successes builds confidence and supports self-efficacy.
Nurse: “Mr. T, on a scale of 0 to 10, 10 being the most confident and 0 being not confident at all, how confident are you that you're ready to start following a diabetes meal plan?”
Mr. T: “I guess about a 7.”
Nurse: “That's interesting. Why 7?”
Mr. T: “I've struggled with my weight all my life. It's really tough for me to say “no” to food. When I hang out with the guys, we eat. When I take my wife out for a date, we eat. When we get together with the family, we eat. It's tough.”
Nurse: ”So food is an important part of your social life.” (This is simple reflection.)
Mr. T: “Yeah, it is. But it certainly wouldn't hurt my friends and family to cut back a little too. We're not getting any younger or healthier. And I sure don't want to see my kids develop this diabetes.”
Nurse: “Your kids are important to you.” (Again, simple reflection.)
Mr. T: “They're my world, and I really need to change something if I want to be around to enjoy them.” (This is change talk.)
Nurse: “Back to the confidence scale: Why did you choose a 7 instead of a 5?”
Mr. T: “I've lost a significant amount of weight in the past and kept it off for almost 5 years, so I know that I can do it again.”
Nurse: “That's fantastic! Tell me more about how you did it.” (This is support self-efficacy.)
Using brief MI techniques
Here are some examples of brief MI techniques that the nurse uses during the course of Mr. T's care to get him thinking and to plant the seeds of change.4,7
1. Ask for elaboration to encourage the patient to expand on a subject before moving on.
Nurse: “So part of you wants to get your blood sugars under control, but the other part of you wants to keep enjoying meals with friends and family. What do you think about that?”
Or when negotiating a plan to implement a change, nurses can simply say, “Tell me more about that.”
2. Look forward to help a patient picture a changed future. This also gives nurses an opportunity to assess how well patients understand the consequences of not engaging in health promotion.
Nurse: “What happens 4 or 5 years from now if you don't get your blood sugars under control? What will that look like?”
3. Ask—provide—ask to give patients an opportunity to integrate the information into their own situation. When nurses hear an opportunity to provide health teaching, they can ask patients if it's all right to share some information with them. Patients need to be open and ready to pick up what nurses are saying. Nurses can provide the education and then ask, “What do you think about that?”
4. Explore the pros and cons of current behavior and the costs versus the benefits of changing that behavior.
Nurse: “What are some of the benefits of continuing your current food habits?”
Mr. T: “I enjoy going out to eat and drink with friends and family, which makes me feel good at the time.”
Nurse: “How do you think it's hurting you?”
Mr. T: “It raises my blood sugar. It's caused me to gain weight. I don't take pride in my appearance anymore. I get winded walking up the stairs.”
Nurse: “What would you gain by cutting back on your food intake?”
Mr. T: “I'd be able to go out and catch the football with my grandson or take my granddaughters to the zoo. I wouldn't be so self-conscious about my appearance. I wouldn't have high blood sugars so I probably wouldn't be in the hospital so much.”
Nurse: “Those all sound like wonderful reasons to start watching your diet. And it sounds like you'd be able to enjoy family time without always going out to eat. What do you think?”
5. Ask evocative questions to explore the person's own perceptions and concerns.
Nurse: “Your family is very important to you. What's the impact on them if you continue your current lifestyle? How do your actions affect them?”
Mr. T, along with his wife, came up with a plan to make some practical dietary changes together, starting by substituting sparkling water for high-calorie carbonated beverages. At his 6-week follow-up appointment, he'd lost 3.6 kg (8 lb). His BP was 142/84, and his pulse, 86. He kept a diary of daily blood glucose levels, none of which were over 214, and had adhered to his insulin regimen. He reported feeling more energetic and was motivated by his positive results to implement additional small changes.
Focus on the journey, not the destination
Communication in medical care is highly correlated with better treatment adherence, and the use of MI is becoming widely accepted by healthcare providers across disciplines and settings.4,6 The skillful clinician can tailor questions to evoke self-reflection and set the foundation needed to successfully motivate behavior change that positively impacts immediate and long-term health.9
But MI is as much a way of relating to patients that conveys respect for their decisions as it is specific techniques to elicit change talk. The skillful practitioner is empathetic, accepting, optimistic, and affirmative. To make behavior change a reality, successful practitioners need to support patients' sense of responsibility, empowerment, and self-confidence.
Using OARS to propel MI10
MI uses a basic communication style represented by the acronym OARS:
* Open questions that lead to more explanation and further contemplation.
* Affirmations that promote positive feelings in the exchange.
* Reflections to prove the clinician's heard and truly understood the patient.
* Summaries, which build on simple reflections to foster momentum or generate interest in making changes.