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Running head: MOTIVATIONAL INTERVIEWING 1
Motivational Interviewing Clinical Public Health Intervention
Diana Wiseman
University of New Hampshire: NURS 704C
MOTIVATIONAL INTERVIEWING
Introduction
The purpose of the nursing health education intervention is to increase the nurse’s ability
to promote healthy behaviors. The intervention is intended to provide the nurses a skill that will
assist them in helping patients make behavioral changes to benefit their health. Health coaching,
commonly known as motivational interviewing, is used to elicit behavioral changes in patients or
clients. Initially, the intervention was planned to be targeted directly at the patients to increase
their knowledge or better their condition/experience. However, as data was collected and
analyzed, it became evident that the most effective way to help the patient population was to give
the nurses the tools necessary to better support their patients.
Motivational interviewing is a technique in which the interviewer works in collaboration
with an individual to help him or her address their ambivalence about health behavior change
(Huffman, 2010, p. 245). The conversation helps the individual find their own personal
motivation to make behavioral change, compared to the traditional method where the educator
(provider or nurse) tells the patient what to do. It allows the patient to weigh the benefits and
consequences to change, and through conversation with a motivational interviewer for the
individual to find their motivation as they reflect on the benefits of change.
Motivational interviewing began with Miller and Rollnick in the 1980s when the method
was first used on people who had issues with alcohol abuse. For these individuals, it is often
difficult to find a motivation to quit however, the success with motivational interviewing was
impressive and slightly surprising (Huffman, 2010, p. 246). Following the success of
motivational interviewing with problem drinking, the method was applied to individuals with
chronic conditions.
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The idea behind motivational interviewing is very unique to healthcare practitioners
because typically practitioners work based on their own personal agenda and teach the topics
they feel are important (Huffman, 2010, p. 246). Conversely, motivational interviewing
“engages the individual to actively discover why they are ambivalent about change, integrating
health teaching during the process” and “it is the individuals agenda, not that of the health care
professional, that directs the course for change” (Huffman, 2010, p. 246).
Butterworth (Healthcare Intelligence Network, 2007, p. 8) identified eight reasons why
clients were not compliant with treatment plans. Of the eight, none included a lack of knowledge
or understanding, implying that education alone will not cause behavioral change (Huffman,
2010, p. 246). A effective health coach is “nonjudgmental, listens effectively, elicits what is
important to [the client], helps set safe and realistic goals, gives objective feedback, guides
[client] to identify both obstacles and support, helps develop a plan of action, and instills
accountability for change” (Huffman, 2010, p. 246).
Assessment
The health education project was directed at the Rockingham Visiting Nurse Agency, a
community health organization. In the preplanning stages, qualitative data was collected from
Michele Langdon, RN on the Epping team, regarding her perspective on an unmet health
education need for her patient population. Michele felt strongly that the most prominent and
detrimental issues she sees is patients who are noncompliant with medication therapy.
Qualitative data was also collected from Jeanie, an LPN on the Epping team. Jeanie also stated
medication adherence was a common issue among patients.
Data was then collected through observation of Michele Langdon’s case load. Michele
frequently had patients that required wound care and she reported accounts of nurses in the
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agency who incorrectly assessed and treated wounds. After gather data from Michele, Jeanie,
and through observation, the unmet health education need was narrowed down to education on
wound care and medication compliance. The information was then used to form a survey to
better understand what issue affected the most number of nurses and patients. Please see
Appendix A for survey questions. The survey gathered data in a quantitative manner and
assessed nurses’ skills and knowledge on wound care, and on Prochaska’s behavior change
theory and motivational interviewing. Prochaska’s behavior change theory and motivational
interviewing were included because they are tools which can assist nurses in helping their
patients adhere to their medication therapy or make other behavioral changes. Therefore,
motivational interviewing would provide nurses with one skill that could be used in diverse
scenarios. It was important to use the survey to dictate the intervention because the education
provided would only be useful if the nurses felt it was something they needed to know or would
benefit from.
Although it was easy to form a survey for the nurses to take, it was very challenging
to reach the nurses and have them complete the survey due to the nature of the agency. Visiting
nurses do not work out of their agency and typically only go to the agency every few weeks.
After multiple attempts the survey was finally distributed at the VNA’s skill seminar. The nurses
were handed a survey upon the completion of their flu shot. Data was collected from twelve
nurses.
The data collected showed that most of the nurses were confident or somewhat confident
in their ability to assess wounds. The nurses ranked how confident they were on a scale of 1 to
5, 1 being not at all confident and 5 being confident with all wounds. Only 8% chose a 1 or 2.
Based on this feedback, especially in comparison to the rest of the data, teaching the nurses about
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wound assessment would not be an effective intervention because the nurses felt confident in the
skill.
However, when asked about Prochaska’s behavioral stages of change, 92% of the
participants said they were not familiar with it. All of the participants indicated they did not use
Prochaska’s stages of change to assist patients in medication adherence. Interestingly, 50% of
the respondents said they knew what motivational interviewing was and 50% said they used
motivational interviewing. Please see Appendix B for survey results.
The results are interesting in that the nurses did not know what Prochaska’s stages of
change were but they did know about motivational interviewing. Typically the two concepts are
used simultaneously. The assessment showed an unmet education need based on the data that
92% of the nurses did not know what Prochaska’s stages of change were and that 50% of the
nurses did not know what motivational interviewing was and did not use it. Therefore, the
intervention was planned to teach the nurses at the Rockingham VNA about motivational
interviewing and Prochaska’s stages of change. The skill of motivational interviewing,
otherwise known as health coaching, can help nurses elicit behavioral change in their patient,
which may include medication adherence.
Although the data collected indicates that education on motivational interviewing would
be a beneficial skill for the patients seen by the nurses at the Rockingham VNA, national data
concludes the same. Approximately 50% of patients in the United States do not follow their
healthcare treatment plan and nearly double that number do not comply with dietary restrictions,
exercise, or restrictions on behaviors that compromise health (Gance-Cleveland, 2005, p. 151).
Therefore, the national population would benefit from motivational interviewing as a means to
assist them in making behavioral changes.
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Literature Review
The effects and benefits of motivational interviewing have been studied and tested in
multiple research studies. A systematic review looked at the effects of motivational interviewing
on cardiovascular health. Studies were identified from the following databases: CINAHL,
Medline, PsycINFO, Cochrane Library, EBSCO, Web of Science, Embase and British Nursing
Index (Thompson et al, 2011). The studies used were published in 1999-2009. Following the
systematic review, it was found “the evidence indicates that motivational interviewing is a useful
approach to behavior change” (Thompson et al, 2011, p. 1242). Also the study concluded that
motivational interviewing “is superior to ‘traditional’ advice, improves with increased intensity
(number and length of encounters) and appears effective even with brief encounters” (Thompson
et al, 2011, p. 1242). The intervention for the study by Thompson et al taught nurses how to do
brief encounters; therefore this information was crucial in the development of the intervention
for the VNA nurses.
Motivational interviewing was also studied to determine the benefits in adults receiving
outpatient hemodialysis. The study examined the effects of motivational interviewing on
twenty-nine participants. Prior to the study, data on adherence for each patient was collected for
three months. The motivational interviewing intervention then followed for a three month
period. Finally, each participant was followed for three month post-intervention adherence data
(Russell et al, 2011). The results from the study are limited because five participants had to drop
out for reasons unrelated to the study. From the small sample size of nineteen, the study found
that motivational interviewing “appeared to favorably influence dialysis attendance, shorten
treatments, and phosphorous and albumin levels” (Russell et al, 2011, p. 233). An example of
the success of the motivational interviewing can be seen in adherence to dialysis schedule. Prior
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to the intervention 74 percent of the participants reported never missing treatments. After the
intervention, 95 percent of the participants reported never missing treatments. The study
measured adherence based on five criteria: missed treatments, shortened treatments, interdialytic
weight gain, phosphorous levels, and albumin levels. The study found that “four of the five
adherence outcomes showed improvement after the three-month staff-delivered motivational
interviewing intervention” (Russel et al, 2011, p. 235).
The effect of motivational interviewing on smoking cessation in pregnant women was
studied by Karatay, Kublay, and Emiroglu. The study included thirty-eight pregnant women
who smoked at least one cigarette a day and had not reached their 16th week of pregnancy. Each
woman received eight home visits, five for the intervention and three for follow-up (Karatay et
al, 2010). Data collected to determine the success of the intervention included: an evaluation
form, carbon monoxide level in expired air, cotinine measurements and a self-efficacy scale.
The end result showed that 39.5 percent of the woman gave up smoking and 44.7 percent of the
woman decreasing the amount they smoked by 60 percent. Also, three months following the
study, 39.5 percent of the women continued in the action stage of the transtheoretical model
(Karatay et al, 2010).
Motivational interviewing has also been used with alcohol abuse in my studies. Monti et
al aimed to “establish the efficacy of a brief motivational intervention compared to feedback
only when delivered in an emergency department for reducing alcohol use and problems among
young adults” (2007, p. 1234). All 198 participants were either positive for alcohol upon
hospital admission or were found to have alcohol problems based on screening at a level I trauma
center (Monti et al, 2007). The participants were randomly assigned to the experimental group,
which receive a one session motivational intervention (MI), or to the typical treatment group,
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which received personalized feedback only (FO). All the participants received a phone call one
month and three months after the intervention. The follow-up tests “showed that the MI group
had significantly greater reductions in consumption than FO on all three consumption measures
at both 6 and 12 months” (Monti et al, 2007, p. 1238). Also, “from baseline to 12 months MI
patients reduced consumption by 45-53%, depending on the measure, whereas FO reduced
consumption by 11-18%” (Monti et al, 2007, p. 1238).
Planning Interventions
A major partner in the production of the intervention was Donna Pelletier, DNP, APRN,
FNP. Pelletier, who is certified in health coaching at the University of New Hampshire,
provided information about the “brief negotiation roadmap” and how to follow it, as well as the
use of the readiness and confidence ruler. Pelletier, who often teaches other healthcare
professionals how to use health coaching in their daily patient interactions, had advice from her
experience as to effective teaching techniques. When she taught how to follow the “brief
negotiation roadmap” she did so with an example of what the provider may say, as well as how a
patient may respond. This technique gave the learner a more realistic perspective of the process.
Pelletier also stated that she often has the healthcare professionals she is teaching role-play.
Many of the health coaching and motivational interviewing books have scenarios of patient-
provider interactions with and without the use of motivational interviewing.
“Motivational Interviewing in Nursing Practice: Empowering the patient” by Michelle A.
Dart also served as an important resource in planning the intervention. Dart outlined
motivational interviewing from the start when William R. Miller, PhD, published “Motivational
Interviewing with Problem Drinkers” in 1983 (Dart, 2011). Dart defined motivational
interviewing, as well as explained its connection to the transtheoretical model by DiClemente
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and Prochaska. There are four principles of motivational interviewing: express empathy, support
self-efficacy, develop discrepancy, and roll with resistance (Dart, 2011). The four principles are
essential in motivational interviewing because without them, the conversation is not considered
motivational interviewing.
The “brief negotiation roadmap” was developed by Miller, Rollnick, and Permanente as a
“teaching tool to help the practitioner to participate in brief interventions and effectively promote
behavior change” (Dart, 2011, p. 7). Since the “brief negotiation roadmap” was produced as a
teaching tool, the intervention for the nurses of the Rockingham VNA included teaching in this
process.
Implementation
The intervention was implemented at a skills seminar held by the Rockingham VNA at
Exeter Hospital. The VNA had assembled the skills seminar to consist of multiple tables each
hosting a different skill for the nurses to rotate through. Therefore, the intervention for this study
was set up in the same fashion the VNA had assembled their skills. The educator sat at one table
with the necessary supplies and the nurses rotated through the tables.
The intervention was intended to support different learning styles. Therefore, the final
intervention included multiple elements that addressed visual and auditory learners. A tri-fold
board displayed an enlarged “brief negotiation roadmap” as well as principles of motivational
interviewing and concepts of successful health coaching (Dart, 2011, p. 4) (Huffman, 2010, p.
246-7). The tri-fold board supported visual learners by outlining the entire process of health
coaching or brief motivational interviewing.
Each participant engaged in a one-on-one learning session with the educator. During the
engagement, the educator explained how to use the “brief negotiation roadmap” to direct a
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motivational interviewing conversation. During the explanation, the educator also provided the
learner with a sample scenario and reviewed how to use the principles of motivational
interviewing. The spoken explanation was intended to assisted auditory learners.
Following the explanation, the educator allowed the learner to select a script about blood
sugars, hypertension, or COPD. The learner and educator read the script together where the
learner played the role of the nurse and the educator played the role of the patient. The scripts
were sample scenarios of a conversation without motivational interviewing and then the same
conversation using motivational interviewing. Again, reading the scripts was intended to
facilitate learning for auditory learners. Finally, the learner was given a take home reading about
motivational interviewing titled “Health coaching: a fresh, new approach to improve quality
outcomes and compliance for patients with chronic conditions” by Melinda Huffman (2009).
The reading was planned to help the visual learners in understand health coaching. The session
concluded with the learner completing an evaluation on the intervention. Please see Appendix C
for visuals of the event.
Evaluation
Intervention Assessment
Overall the feedback from the evaluation was positive and appeared to indicate a
successful intervention. There were a total of twelve participants and all participants filled out
an evaluation. 50 percent of the participants indicated it was the first time they learned about
health coaching or motivational interviewing. All participants (100%) specified they felt they
had the knowledge necessary to perform motivational interviewing. Additionally, all of the
participants (100%) indicated they felt they had the skills necessary to perform motivational
interviewing. Having the knowledge and skills are very different aspects and having both allow
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an individual to effectively perform motivational interviewing. 92 percent of the participants
indicated they would incorporate health coaching in their future practice. 88 percent of the
participants felt the education was “very helpful” and the other 17 percent felt it was “helpful.”
Finally, the survey gathered qualitative data by asking what the participant liked about the
presentation and if he or she had any suggestions. Answers varied regarding what the participant
liked about the presentation. However, overall most participants felt that the presentation was
easy to understand, clear, and well presented. A few participants also commented on enjoying
the role playing/scenarios. No suggested were included. Please see appendix D for complete
results.
Strengths
Positive feedback came from the skills seminar leader, Erin Magoon. She discussed
having the entire Rockingham VNA agency receive the intervention because she felt the skill
was very useful. Also, Erin stated she had learned about motivational interviewing before but,
she felt that the way it was presented through this intervention was easier to understand and
follow.
Weaknesses
There were many limitations to the study. The sample size was one major limitation.
Also, the evaluation survey was a limitation because it only assessed short term outcomes.
Although 92 percent of participants indicated they would incorporate motivational interviewing
into their future practice, it does not guarantee they will. Ideally, long term outcomes would be
assessed as well.
During the implementation of the intervention many nurses did not appear to think that
the motivational interviewing skill was mandatory because it was not on the skill checklist
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produced by the Rockingham VNA, which was another limitation. It took some encouraging
from the skills seminar leader for the nurses to come to the motivational interviewing table.
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References
Dart, M. (2011). Motivational interviewing in nursing practice. (pp. 1-228). Sudbury, MA: Jones
and Bartlett Publishers.
Gance-Cleveland, B. (2005). Motivational interviewing as a strategy to increase families’
adherence to treatment regimens. JSPN, 10(3), 151-154.
Healthcare Intelligence Network. (2007). Coaching in the healthcare continuum: Models,
methods, measurements and motivation. Manasquan: NJ.
Huffman, M. (2010). Health coaching: a fresh approach to improving health outcomes and
reducing costs. AAOHN Journal, 58(6), 245-252. doi:10.3928/08910162-20100526-02
Huffman, M. (2009). Health coaching: a fresh, new approach to improve quality outcomes and
compliance for patients with chronic conditions... Dr. William Miller. Home Healthcare
Nurse, 27(8), 490-498. doi:10.1097/01.NHH.0000360924.64474.04
Karatay, G., Kublay, G., & Emiroglu, O. (2010). Effect of motivational interviewing on smoking
cessation in pregnant women. Journal Of Advanced Nursing, 66(6), 1328-1337.
doi:10.1111/j.1365-2648.2010.05267.x
Monti, P., Barnett, N., Colby, S., Gwaltney, C., Spirito, A., Rohsenow, D., & Woolard, R.
(2007). Motivational interviewing versus feedback only in emergency care for young
adult problem drinking. Addiction, 102(8), 1234-1243.
Russell, C. L., Cronk, N. J., Herron, M., Knowles, N., Matteson, M. L., Peace, L., & Ponferrada,
L. (2011). Motivational Interviewing in Dialysis Adherence Study (MIDAS). Nephrology
Nursing Journal, 38(3), 229-236.
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Thompson, D., Chair, S., Chan, S., Astin, F., Davidson, P., & Ski, C. (2011). Motivational
interviewing: a useful approach to improving cardiovascular health?. Journal Of Clinical
Nursing, 20(9/10), 1236-1244. doi:10.1111/j.1365-2702.2010.03558.x
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Appendix APre-Survey for VNA
1. On a scale of 1-5 how confident are you in assessing a wound? 1 2 3 4 5 (1-not at all confident, 5-confident with all types of wounds)
2. Based on your wound assessment how comfortable/confident are you: (1-not at all confident, 5-completely confident)
-packing a wound with Iodoform 1 2 3 4 5
-applying a wet to dry dressing 1 2 3 4 5
-applying a hydrocolloid dressing 1 2 3 4 5
-applying a hydrogel (Aquasorb) dressing 1 2 3 4 5
3. A review/refresher of which of the following would be most useful to you?
-types of tissue in the wound bed (example: necrotic, slough, granulation, epithelial, closed/healing)
-different stages of pressure ulcers and how to stage a pressure ulcer
-types of drainage, including characteristics such as consistency, color, odor and possible meaning
4. Are you up to date on the newest dressing options? Yes / No
5. Do you know what Prochaska’s behavior change theory is (Transtheoretical Model of Behavior)? Yes /
No
6. Do you use Prochaska’s behavior change theory to assist in medication compliance amongst patients? Yes
/ No
7. Are you familiar with motivational interviewing? Yes / No
8. Do you use motivational interviewing with your patients? Yes / No
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Appendix BPre-Survey Results
1 2 3 4 5
1. How confident are you in assessing wounds 0% 8%
42%
8%
42%
(1= not at all confident, 5= confident with all types of wounds)
2. How confident are you in the following (same scale)? 1 2 3 4 5
-packing a wound with Iodoform25% 0% 8%
17%
50%
-applying a wet to dry dressing 0% 0%33% 8%
58%
-applying a hydrocolloid dressing 8% 0%33% 8%
50%
-applying a hydrogel (Aquasorb) dressing 8% 0%25%
17%
50%
3. A review of which topic would be most helpful
** 2 sets of answers thrown out-done incorrectly
-types of tissue in the wound bed50%
-different stages of pressure ulcers and how to stage them30%
-types of drainage (including characteristics of each)20%
4. Are you up to date on the newest dressing options? yes no
** 1 person did not answer55% 45%
yes no
5. Do you know what Prochaska's behavior change theory is? 8% 92%
6. Do you use Prochaska's behavior change theory to assist in medication compliance with patients? 0%100%
7. Are you familiar with motivational interviewing?50% 50%
8. Do you use motivational interviewing with your patients?50% 50%
Survey administer to Rockingham VNA (n=12).
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Appendix CImplementation
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Appendix DEvaluations
1. Was this your first time learning about health coaching/motivational interviewing?
Yes: 6(50%) No: 5(42%) No answer: 1(8%)
2. Do you feel you have the knowledge necessary to perform health coaching?
Yes: 12(100%) No: 0(0%)
3. Do you feel you have the skills needed to perform health coaching?
Yes: 12(100%) No: 0(0%)
4. Will you incorporate health coaching in your future practice?
Yes: 11(92%) No: 0(0%) No answer: 1(8%)
5. How helpful was this teaching? 1 2 3 4 51= not helpful, 3=somewhat helpful, 5=very helpful
1: 0(0%) 2: 0(0%) 3: 0(0%) 4: 2(17%) 5: 10(88%)
6. What did you like about the presentations: “easy to follow and clear poster” “clear” “the way it was presented out outlining
the benefits for both patients and nurses”
“the poster was straight forward and the speaker very knowledgeable and had passion for the project”
“how it gives the patient control” “the actual scenarios” “one-on-one, role playing, relaxed” “simple to understand a complex idea” “organized, well presented” “presentation was great” “the role acting really shows the
process the best” “informative/poster”
7. Any suggestions? “Good job” “No” “Thank you”
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