Each day seems to bring about new challenges for healthy living. This has been especially true over the past 2 years as the COVID-19 pandemic swept across the world, exacerbating existing social problems and contributing to increased stress levels worldwide. Fear, isolation, poverty, unemployment, food and financial insecurity, and civil unrest have led to a general feeling of uncertainty about the future. In one study, 60% of Americans reported feeling very stressed and overwhelmed due to the issues they're currently facing.1 These compounding stressors have real consequences on our physical and mental health; unfortunately, reported stress levels are getting higher instead of lower.1
Many people aren't prepared to cope with the stressful situations in which they find themselves, and they don't know what to do or where to go for help. During periods of high stress, people try to cope using whatever means they can to help alleviate the situation and feel better. However, not all coping mechanisms are created equal. Some are helpful and promote adaptation to stress, whereas others are maladaptive and can increase overall stress and worsen the situation.1 The use of alcohol, drugs, tobacco, and uncontrolled eating are just a few examples of maladaptive coping behaviors. Although they may briefly elicit a feeling of control and well-being, these behaviors can become habitual/addictive, requiring more of the behavior to elicit the same response, and behavior change is extremely difficult.2,3
High levels of stress can also significantly affect people with chronic illness by reducing their adherence to the prescribed treatment, such as medication, diet, and exercise.4 This lack of adherence may not be intentional, but increased stress can make it more challenging to follow through with recommendations that are expensive, time-consuming, or not enjoyable. Failure to adhere to treatment often results in poor health outcomes, including increased or prolonged hospitalization and death.5
Nurses often find themselves in the position of identifying and discussing maladaptive behaviors with patients. A significant function of the nurse's role is to provide health education and assist patients with improving their health, and this includes helping them recognize, understand, and change maladaptive behaviors.6 The nurse's approach to communicating with the patient about the behavior is essential for a positive outcome.
In this article, we discuss motivational interviewing (MI), an evidence-based technique for nurses to help patients make healthier lifestyle choices related to maladaptive behaviors, both psychological and physiologic.7,8 This collaborative, goal-oriented style of communication focuses on the language of change and is designed to strengthen a patient's motivation for and commitment to a specific goal by eliciting and exploring their reasons for change within an atmosphere of acceptance and compassion.9
Basic principles
Evolving from experiences treating alcoholism, the concept of MI was first described by American psychologist William Miller in 1983. Miller and Rollnick defined MI as "a directive, client-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence."10 Miller and Rollnick also gathered inspiration from Carl Rogers' work on nondirective counseling.11 The core principle of this approach is negotiation rather than conflict. Through clinical experience and empirical research, the fundamental methodologies of MI have been applied and tested in various settings, and research findings have demonstrated their efficacy.9
MI is characterized by a collaborative partnership, with the nurse using acceptance, compassion, and evocation to interact as an equal partner with the patient.10 The goal is to increase the patient's motivation or commitment to change by helping them recognize the thoughts, feelings, and insecurities related to unwanted behavior. Change can't occur if the patient is passive; the nurse and patient must work together to achieve a common goal.12
The transtheoretical model for stages of change provides a framework to guide the application of MI in practice (see The six stages of change13). This model is used to assess a person's readiness to act on a new healthier behavior and provides strategies to guide them in accomplishing change.14 Ideally, a person starts at the first stage and progresses through to the end where behavior is changed; however, they may also go back and forth between stages.
To make and maintain the change, a person must have:15
* a growing awareness that the advantages of changing the behavior outweigh the disadvantages
* confidence that they can make and maintain changes even when they're tempted to return to the old behavior
* strategies to help them make and maintain the change.
The process
The goal of each MI session is to encourage the patient to talk about the unwanted behavior through engaging, focusing, evoking, and planning (see The four processes MI11). The MI process is relatively simple and begins with the nurse establishing a relationship with the patient, then setting an initial agenda for future behavior change work. They discuss the behaviors the patient would like to change, and the patient selects one behavior on which to focus future work. Through conversations, the nurse and patient determine the importance of the problem selected, as well as the patient's confidence in their ability and readiness to change the behavior. The nurse explores the importance of making this change in the patient's life and reinforces positive statements directed at success. Finally, the nurse and patient can work together to develop a plan with specific strategies for accomplishing the change. These processes occur somewhat sequentially but overlap across time. The patient is in charge of making all decisions related to the change process, which allows them to find and consider options for change that decrease or eliminate the maladaptive behavior.16,17
As a healthcare provider, it's easy to assume people are ready to change when they seek treatment; however, they often have varying levels of willingness to change (see The five basic assumptions of the MI process11). Barriers, such as denial or resistance to change, may exist. Evaluating the patient's willingness to decrease or stop the maladaptive behavior without trying to persuade them to do something is an important part of the nurse's role in MI. Four core communication skills or components, known by the acronym OARS, are central to the MI process18,19 (see OARS core communication skills20).
To begin the MI process, create a private and comfortable environment. This is essential to enable you to focus on empathetic listening, which will help the patient identify and target the needed change. It's important to try to view the world through the patient's eyes and experience the world as the patient experiences it.21 The first OARS skill is asking open-ended questions, which allows the patient to do most of the talking and enables you to explore and gain an understanding of the patient's world.18 Ask "how" or "what" but avoid asking "why" because it tends to make a person defensive. Using "how" or "what" questions can elicit additional information without asking the patient to justify a decision or behavior.
The second OARS skill is affirmation, which helps you acknowledge the positive aspects of the patient's situation. Making affirming statements aids the patient in recognizing their positive behaviors and strengths and builds confidence in the ability to change.22 These statements let the patient know that their concerns and issues are valid, conveying respect and appreciation for the patient's willingness to make small changes.
Reflecting, often known as reframing, is the next and probably most difficult OARS skill.18 The ability to accurately reflect what a patient says is highly dependent on your ability to be an empathetic and intent listener. You must be aware of the many roadblocks to the listening process to prevent derailing the conversation and disrupting the therapeutic relationship (see Roadblocks to effective communication during MI10).
Listen as the patient discusses the maladaptive behavior and observe their body language, mannerisms, and behavior during the discussion. By reflecting back what you hear, feel, or see during the conversation, you can guide the patient to be a more independent thinker and, eventually, help them create a plan for change.12 Reflecting can be used as an invitation for the patient to examine their perception of the behavior in a new way.
The last OARS skill is summarizing, which keeps the nurse and patient "on the same page" throughout the process. Summary statements pull together everything that has been said during the conversation to help the patient develop their plan of action and prepare for what needs to occur.18
Nursing considerations
The interaction process-developing discrepancy, expressing empathy, amplifying ambivalence, rolling with resistance, and supporting self-efficacy-helps guide the MI session by focusing on empowering the patient (see Principles of the interaction process12).
Developing discrepancy. During the MI process, you may identify discrepancies, or gaps, between where the patient was (or is) and where they want to be. Pointing out these discrepancies can help the patient realize that the unwanted behavior isn't leading toward the desired goal and may actually be preventing them from achieving the goal.12 As a result, the patient can become more motivated and open to change.
Expressing empathy. To express empathy effectively, you must try to understand the situation from the patient's perspective. When people feel understood, they're more likely to trust you and share information and experiences that are critical to the MI process.
Amplifying ambivalence. Being ambivalent to change is normal, but ambivalence can cause the patient to become paralyzed and fail to move forward. Explore this ambivalence with the patient to help them work through pros and cons of the needed change. When these discussions don't occur, behavior change is less likely to happen.
Rolling with resistance. During the conversation, you may perceive the patient's resistance to change. This may be evident when they argue with or interrupt you, deny problems, or ignore what's being said. Resistance may occur if you move the patient ahead too quickly or fail to understand something that's important to them. When there's resistance, it's time to change your communication strategy to focus more on collaboration.
When an argument occurs, stop the conversation and indicate your intent to understand what the patient is thinking or feeling. To change direction, return to the OARS skills of open-ended questions, affirmation, reflective listening, and summarizing to learn more about why the patient is feeling resistant. Accept the patient's perception of the situation as real and remember that they have the solution to the problem. Avoid "driving" the conversation and don't tell the patient what to do or how to resolve the situation. If a patient sees no possibilities for a goal to be reached, it's likely they won't put forth the effort needed for change.
Supporting self-efficacy. Identify and point out the patient's previous behavioral and life successes, along with strengths and skills, to help them feel that they're capable of achieving the change.
At some point during the MI process, the patient will provide some indication of a willingness to move forward with developing a plan for change. The first step in the planning process is to identify a clear goal. Together, you and the patient can brainstorm and consider all the possible ways to achieve the goal. It's helpful to put the goal and strategies for goal attainment in writing, so it can be reviewed in the future.
After summarizing the plan, ask the patient about their commitment to it. The simplest way to do this is to ask, "Is this what you want to do?" If the patient wavers on commitment, continue to use OARS skills to determine what's holding them back and promote commitment. If the patient does commit to the change plan, this commitment can be strengthened if they make it public by sharing with friends, family, and others.12
Change can be painful and difficult. There may be setbacks in the process, and several attempts may be required for the patient to adopt a healthier lifestyle. Although part of the nurse's role is to recognize maladaptive behaviors and teach patients more appropriate coping skills, it may be frustrating to work with someone who continues to practice unhealthy or self-destructive behaviors, such as addiction or nonadherence to treatment. To be effective, you must be patient.12 Achieving goals may require numerous discussions and extensive support from yourself and others.
Nurses who have limited time to meet with patients or those who are rushed to cover a busy caseload may find it difficult to fully implement the principles of MI. In addition, nurses who offer advice or have difficulty allowing patients to make their own decisions likely won't be successful with the MI approach. Components of the MI process aren't always instinctive and learning how to work with patients using MI takes time and practice. Find a quality training program to learn how to use MI effectively and ethically (see Training resources for MI).
Benefits and limitations
MI has many benefits, including building patients' self-confidence and helping them learn to take responsibility for themselves. This technique demonstrates to patients that they have the power to stop dangerous or destructive behavior and change their lives.23 MI is an excellent tool to address addiction, such as alcohol or drug abuse and tobacco use, and help patients recognize how these behaviors impact their lives. The MI process can be used to teach new coping mechanisms to use and results in positive change.24
There may be difficult emotions, such as anger, hostility, and frustration, that contribute to the maladaptive behavior. MI can be successfully used to manage these emotions, so changing the behavior becomes easier to accomplish. Patients may have disorders co-occurring with addiction, such as bipolar disorder, anxiety, and depression, and they may have difficulty seeing or understanding the need for change.24
MI has also been successfully used to help patients manage chronic conditions, such as obesity, congestive heart failure or other heart diseases, diabetes, and asthma.25 The goal is for the patient to learn to manage their chronic condition by making better choices about medication, diet, exercise, or adherence to other treatment recommendations. To be successful, patients need to accept that change is necessary, make a commitment to change, and believe their health condition may improve because of the change or at least be willing to try.24
Limitations to the use of MI are few. A person who's ambivalent about changing their behavior, habits, or lifestyle or who doesn't believe they have a problem that needs to be changed is likely not ready for the MI approach. People who are experiencing the acute effects of serious trauma, depression, or illness may need time to stabilize and focus on other issues before working on behavior change. In addition, MI is generally not the primary clinical approach for people with serious mental health disorders, such as bipolar disorder or schizophrenia, but it may be used in conjunction with other interventions such as medication and case management.11
Toward a healthier life
In response to life stressors, people may develop unhealthy coping mechanisms, which result in maladaptive behaviors that are difficult to change. MI is an evidence-based, directive, patient-centered counseling style used to elicit behavior change by helping patients explore and resolve ambivalence. The MI process is straightforward and depends on several communication skills designed to build confidence and encourage patients to attempt change. MI has been used for many years to help people successfully change behaviors and return to a healthier lifestyle.
The five basic assumptions of the MI process11
* Motivation is a temporary condition, not a personality characteristic.
* Resistance is a strategy to change, not something to overcome.
* Ambivalence is good.
* The patient should be an ally, not an adversary.
* Recovery and change are essential to the patient.
memory jogger
OARS core communication skills20
O Ask OPEN-ENDED questions
Examples: "How can I help you today?" "What has worked for you in the past?" "When that happens, how do you feel?"
A Offer AFFIRMATION
Examples: "I'm so glad you came in today." "You're really taking care of yourself."
R Practice REFLECTIVE listening
Examples: "So, you're feeling sad because your daughter has gone away to college?" "When you talk about your father, you seem really angry." "So, you said you don't think you can stop smoking as long as your wife continues to smoke?"
S SUMMARIZE the discussion
Examples: "Let's go over what we've discussed so far. A few minutes ago, you told me about your work situation. Maybe this would be a good time to talk about your stress level."
Roadblocks to effective communication during MI10
* Giving advice
* Making suggestions
* Providing solutions
* Persuading
* Arguing
* Lecturing
* Disagreeing
* Criticizing
* Blaming
* Shaming
* Distracting
* Labeling/unconscious bias
* Interpreting
* Analyzing
* Reassuring
* Consoling
* Sympathizing (rather than empathizing)
* Asking closed-ended questions
* Withdrawing
Principles of the interaction process12
* Developing discrepancy
* Expressing empathy
* Amplifying ambivalence
* Rolling with resistance
* Supporting self-efficacy
on the web
Training resources for MI
Association for Psychological Therapies:http://www.aptmentalhealthtraining.com/mental-health-courses.html
Motivational Interviewing Network of Trainers:https://motivationalinterviewing.org
Psychwire:https://psychwire.com/motivational-interviewing/training-approach
Stephen Rollnick:http://www.stephenrollnick.com/training/#MentalHealth
INSTRUCTIONS An introduction to motivational interviewing
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