Elizabeth Eccles, MS, RN

A primary role of nurse in health care is to help maximize health in patients across their lifespan

For those with chronic medical conditions nurses promote health through education and addressing psychosocial needs: assessment of response to therapies, early intervention, implementing strategies to prevent disease progression, promote restoration on health, and assist in end of life care

Helping patients alter or change their behavior toward more health

promoting behaviors falls into the nursing domain.

Identify needs (based on health status) Information/education (age, literacy,culture

appropriate) – Education is necessary but frequently not sufficient for significant change)

Consider barriers to change Targeted approach(es) to helping change to

healthier behaviors Support Assess

Motivational Interviewing is one approach that has been

shown to be effective in promoting behavior change

through brief targeted interventions and can be

incorporated into clinical care

“Motivational interviewing is a directive, client-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence”

http://motivationalinterview.org/clinical/whatismi.html

4 principals of MI Empathy Support self-sufficiency Roll with resistance Develop Discrepancy

Motivational interviewing is based on a theoretical framework that posits that:◦ Change occurs in a natural process and occurs in

stages◦ Change is affected by both intrinsic and external

forces◦ Motivation is the key to change and motivation is

fueled by a discrepancy between what behavior is present and what behavior is desired

◦ Ambivalence is a part of the process of initiating change and working to resolve ambivalence is the key to processing change.

If change is a natural process which goes in stages…

MI works by facilitating this natural process Assessing where the person in terms of

stage of change will inform the decision of which type of intervention is best suited

You want to keep the person moving toward the change and to have the motivation for change come from the person themselves not the counselor

Techniques are easily adapted to clinical care setting:

ALWAYS client-centered Intended to be brief Present focused Directed

Empathy – being able to see the world through the clients eyes

Support self-sufficiency Roll with resistance Develop Discrepancy

In HIV care has been used as an approach for promoting behavior change for:

◦ Medication adherence◦ Safer sex and risk reduction◦ Smoking cessation◦ Substance abuse◦ Diet and exercise

Establish a “safe” communication environment

Establish respect for the person’s ability to make their own decisions◦ Privacy◦ Non-judgmental approach◦ Empathic vs. non-confrontational messages◦ Communicate caring◦ Communicate confidence in possibility of change

Open ended questions Reflective, active listening Affirmations and positive reinforcement Provide summary statements to verify or

reframe content Communicate confidence Don’t fight resistance (“roll with

resistance”) Don’t argue Don’t take over the process

Ambivalence is the unsettled feeling when one considers the pros and cons and feels drawn to two behaviors.

Passing through ambivalence is a normal part of the process of change

Working with ambivalence is a key to effectiveness of MI. Think of it as “unsticking”.

• PRECONTEMPLATION• CONTEMPLATION• ACTION ( or Preparation/Action)• MAINTENANCE• RELAPSE

As nurses, we work with people at all stages of change. The challenge is to assess where the patient is so that the appropriate strategy can be utilized.

In earlier phases, the work is more to increase motivation

In later phases it is more to strengthen commitment

At this stage, the person has not yet considered changing a behavior

They may not know that change is needed or that there is a problem

They may be defensive about the behavior They may be resistant to considering change At this stage motivation and ambivalence tend to be

low

GOALS of BRIEF INTERVENTION Develop awareness of the problem Don’t alienate; keep them engaged

STRATEGIES• Get more information; ask for elaboration• Listen to concerns; reframe concerns to tie to problem• Develop rapport; express empathy, caring, concern• Provide information• Look for and support motivators

Person has awareness of the issue Has started to consider possible changes

but is not ready to take action Is aware of some benefits and negatives of

making the change Motivation (can be measured by

importance) and ambivalence start rising

GOALS OF BRIEF INTERVENTION• to move toward preparation/action• Increase awareness of options• Stay engaged, active consideration• Person sees more benefits to change

• STRATEGIES• Active listening, reflecting back (concerns, barriers,

intentions)]• Activate person’s curiosity, ideas, concerns• Build discrepancy• Work with ambivalence directly (“roll with

resistance”)• Continue to facilitate motivation

Try to build confidence (find examples of past successes)

Assess the importance of the change to the person (Try to increase the importance)

Assess the person’s confidence in ability to changeTry to increase confidence (self-efficacy)(higher confidence = higher chance of changeKeep the patient in charge of the process,

solutions need to come from themDecision analysis matrix, realistically consider

positives and negatives

Sometimes broken into preparation/action Person moves from considering change to

making concrete plans and implements the plan

GOALS FOR BRIEF BEHAVIORAL INTERVENTION Continue to build confidence Decrease the barriers to change Try to reduce chance of relapse (identify

pitfalls)STRATEGIES Positive reinforcement for making a plan Reduce barriers, engage the patient in anticipation Encourage realistic levels of change Communicate intention to change, gather support

The person has successfully sustained behavior change for 6 months

GOALS FOR BRIEF INTERVENTION Get them to continue focusing on the

behavior change Reduce chance of relapse

STRATEGIES Help prevent minimization; vigilance Reinforce commitment to change “Lapse” is not a relapse; get back on track

quickly Continue to integrate replacement

activities/behaviors

When someone who has changed a behavior reverts to old behavior. Relapse is a normal part of behavior change and should be anticipated

GOALS OF BRIEF INTERVENTION Re-engagement in process Prevent discouragement or shame overwhelming

the process

STRATEGIES Normalize relapse Non-judgemental attitude Explore triggers Back to earlier stages “not starting from the beginning” – past attempts

provide learning

Transtheoretical Model – Prochaska and Diclemente

MI – Miller and Rollnik Mountain Plains ETC, Motivational

Interviewing, August 2003 http://www.motivationalinterview.org/