By Jason A. Smith, Author
As healthcare professionals continue moving toward a patient-centered model of treatment, certain practices have taken on a greater role. One increasingly prominent practice centers on motivational interviewing as a way to help patients change behaviors, with a focus on helping them understand why those changes are needed.
Motivational interviewing was developed in the early 1980s by Stephen Rollnick, a professor of clinical psychology at Cardiff University in Wales. It was initially designed as a way to help patients with substance abuse issues. In recent years, motivational interviewing also has been used to help people manage their own health behaviors, says Jayne Josephsen, EdD, RN, CCCTM, CHSE, CHPN, professor of nursing at Boise State University in Idaho.
Josephsen has worked in the nursing field for 15 years, following her previous career in social work. She says she sees a significant overlap between those two areas from a patient-perspective model, particularly when it comes to motivational interviewing.
“The patient is the expert on themselves, and the patient has to be part of the healthcare team and the decisons that are made,” she says. “Even if we are an expert in medicine or nursing or something else, we have to have that patient perspective in all of our decision-making. Otherwise, our plan of care won’t be effective.”
At Boise State, nursing students are trained in motivational interviewing to help patients self-manage their conditions. “In our behavioral health nursing class, they have to do a simulation with standardized patients. We also go over it in our care coordination class because motivational interviewing is a competency for national certification as a care coordination and transition management nurse,” she says.
Josephsen notes that a number of techniques are used for motivational interviewing and points to Elicit-Provide-Elicit as one of her go-to strategies.
“That strategy is where you elicit what a patient already knows about a topic, and then you ask them if you can give them additional information once you have a baseline of what they already know,” she says. “The important part of that is to ask permission, because part of motivational interviewing is to help the patient remain autonomous in the process. The last part, after I provide more information, is that I ask the patient what that would mean. It really makes it a patient-centered conversation.”
Josephsen notes that a commonly used element in motivational interviewing calls for healthcare professionals to direct conversations with patients through OARS: Open-ended questions, Affirmation, Reflective listening, and Summary.
“You start with the open-ended question so that you can elicit the patient’s perspective,” she says. “Then, you also want to have affirmation in the conversation because that will build on the strengths the patient already has. We want to affirm that.”
Reflective listening, Josephsen adds, provides a way to further direct patients and to motivate them toward making positive changes.
“Then, the summary is kind of wrapping up the conversation,” she says. “But you can have many summaries with the conversation if it’s a lengthy one.”
Another increasingly used technique within the patient-centered perspective focuses on agenda-setting.
“You’re asking permission: ‘Joe, can we talk about your diabetes today?’ and ‘What would you like to talk about?’” she says. “That lets them set the agenda for the conversation.”
With the advent of motivational interviewing as a strategy of patient care, healthcare professionals have reported both positive and negative results in recent years. One example of positive results from motivational interviewing, she says, can be seen when talking to patients about smoking cessation.
“What really happens in that process is that people kind of identify what their values are,” says Josephsen. “They discover that they really want to stop smoking. They want to spend more time with their grandchildren and the rest of their family. Sometimes with small children, people don’t want to smoke around them.”
Josephsen says that such realizations help patients to identify what is most important for them regarding their overall health and quality of life, thus getting them more involved in the direction of their care.
However, she says, motivational interviewing also carries the risk of negative results if a patient and the provider are not on the same page in determining a course of action.
“A key concept with motivational interviewing is ambivalence,” says Josephsen. “As with everyone, if we want to change behavior, sometimes we’re ambivalent about it. They haven’t really decided if they’re ready for change or if they want to change their behavior. That can be frustrating as a healthcare provider.”
Josephsen notes that key elements in overcoming such ambivalence are to help patients determine what they want, to be empathetic as patients work toward change, and to be as nonjudgmental as possible if a patient takes more time than others to decide on the next phase of his or her care.
“Our role as healthcare providers or case managers is to provide consistent support so that the client does have the ability to change when they choose to,” says Josephsen. “In any conversation with a patient, ask what they know about their disease. What additional information do they need?”
Getting Patients Activated, Engaged
Another crucial element of motivational interviewing centers on patient activation and engagement.
“An activated patient is a patient who understands their role in their own health,” says Josephsen. “A hospital case manager does need to understand how activated a patient is because a patient who is not activated likely won’t participate in self-management post-discharge, which can result in readmission and ER visits.”
Josephsen points out that with an increased focus on the patient-centered perspective in recent years, doctors — particularly those who have worked in the healthcare industry for a long time — have experienced difficulty adapting to the patient-engagement model of care management. For this reason, she advocates that healthcare professionals use a holistic approach to engage their patients.
The transition to a value-based payment system will require that healthcare professionals engage patients in the process, she says.
“In the old model, a patient going to the doctor and doing whatever the doctor says doesn’t work anymore,” says Josephsen. “Doctors need to focus on patient-centered care because we need to understand why patients don’t follow through with the directions their healthcare provider gives them. To do that, we have to provide a holistic patient assessment so we can understand how best to support them in managing their own health.”
Motivation Can Help Difficult Patients
Ken Resnicow, PhD, notes that most addiction counselors now incorporate motivational interviewing in treating their patients.
“Most practitioners are exposed to MI in their training. Some use it with everyone because they use it as their primary approach,” says Resnicow, Irwin M. Rosenstock Collegiate Professor at the University of Michigan’s School of Public Health. His research on motivational interviewing has resulted in numerous articles on the topic.
He says that other counselors use motivational interviewing to address the needs of their more difficult patients.
“It can be a tool in their back pocket or in their primary operating system,” says Resnicow. “It’s not quite the standard of care for primary care medicine. For addiction, it’s a standard of care, but for managing primary care medicine or chronic disease, it’s only used moderately. It’s certainly not universal, and there’s in some cases a lack of evidence to support it.”
He adds that in some instances, there is a “lack of will” among healthcare providers to implement motivational interviewing as a method of patient care. Exceptions to that rule can be found in the Aetna, Blue Cross Blue Shield, and Kaiser Permamente systems, he says.
“They’ve invested a great deal of resources into training providers to learn motivational interviewing,” explains Resnicow. “It goes back at least 10 years, with generally positive results.”
Resnicow notes that physicians and counselors have used motivational interviewing to assist patients in changing their behavior in areas beyond smoking.
“It’s used for chronic disease, blood pressure, blood lipids, diabetes, sexual behavior like condom use, and taking HIV medications,” says Resnicow. “The question is not so much where it’s been used so much as where it’s not been used.”
Resnicow says motivational interviewing has helped to address a majority of the CDC’s top 10 preventable causes of death.
“With the exception of maybe asthma, MI has been tested in at least one randomized trial,” he says.
Resnicow echoes Josephsen’s sentiments regarding effective strategies for employing motivational interviewing with a plan of care. He says “slight changes” in the theory of motivational interviewing have occurred over the years, with a greater emphasis on helping patients to identify the meaning of their behavior change.
He says one method uses a combination of “visualization and verbalization,” asking patients to look forward and see how their life would be different if they made necessary changes to their lifestyle.
“It’s part of a tool called ‘pulling change talk from the patient’ — another concrete strategy in reflective listening,” says Resnicow. “Rather than responding with advice or questions, in MI we encourage clinicians to use reflective statements like, ‘You’re starting to wonder what life would be like without smoking’ — restating what the patient said and understanding the feeling and meaning behind it.”
Resnicow points those seeking to help patients change their behavior to a three-pronged method of motivational interviewing that focuses on exploring, guiding, and choosing.
“It’s derived from Christian theology, but it turns out to be effective in addiction counseling and behavior change in general,” he says. “It’s still an active framework to teach providers how to conceive the sequence of behavior change counseling.
“It’s a sequence of what to do and when,” adds Resnicow. “We want to start with draining the swamp — to let the person express their fears and their resistance so their fears have been neutralized. Then you go to ‘guide,’ which is getting more change talk, getting the person excited about change, and moving them in the direction of change. The final step is ‘choosing,’ which is the planning phase.”
Resnicow adds that strategies for effective motivational interviewing are evolving and are continually being developed to engage the skills necessary to maximize their effectiveness.
“For example, we’re starting to use e-health and artificial intelligence to both train practitioners and to deliver the intervention to patients,” he says.