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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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