Bob is diabetic, overweight, and smokes a pack of cigarettes daily. Repeated teaching sessions make no difference in helping him modify his health habits. Sandy's blood pressure runs greater than 140/90 but she doesn't like taking antihypertensive medications or modifying her high-sodium diet. Roy knows he needs to complete physical therapy exercises daily to strengthen his back and legs but does not do so, even though it would decrease his pain and make work easier.
WHAT HELPS PEOPLE CHANGE?
Healthcare clinicians have been trying to change behavior for thousands of years-with modest success at best. Even with the high-tech tools available today, little advancement has been made in changing poor health behaviors related to alcohol, smoking, medication adherence, eating, and exercise habits (King, Mainous, Carnemolla, & Everett, 2009). Short-term gratification is a greater incentive than the possibility of long-term harm, and people tend to do the opposite of what they should or what they are instructed. Telling people to change simply does not work. Unless we see the need or have a desire for change and take responsibility for changing, change is unlikely.
Are there more effective ways to introduce and motivate patients to change health behaviors? Thankfully, yes! The purpose of this article is to introduce nurses to motivational interviewing (MI) and provide an overview of how clinicians can use this interaction style to help patients move toward behavioral change.
THE CHALLENGES OF CHANGE
The difficulty with change is not new. In ancient times, the Apostle Paul wrote, "I do not understand what I do. For what I want to do I do not do, but what I hate I do" (Romans 7:15, NIV). A recent article in The Washington Post describes this tendency:
...despite protestations to the contrary, Americans don't like change...(and) are in total agreement that the current situation is intolerable...But as soon as it seems change might actually happen, as soon as we leave the abstract for the particular-we panic...Sure we want change-as long as everything can stay just as it is (Kinsley, 2009).
When it comes to health changes, lifestyle behaviors such as smoking, alcohol, promiscuous sexual activity, high-fat and high-sodium diets, inactivity, and poor adherence to treatment are risk factors for illness and disease. These behaviors are modifiable (Grundy, 2007; Van Nes & Sawatzky, 2010), but regrettably, a 2009 report shows we may not be moving in the right direction on health behaviors. Obesity in the United States increased from 28% to 36% over the past 18 years and regular physical activity decreased from 53% to 43%. Over 90% of adults have one or more of the following conditions: hypertension, hyperlipidemia, diabetes mellitus, overweight or obesity, and tobacco use. Sadly, adherence to healthy habits in individuals with these conditions is poor (King et al., 2009).
If people know behaviors can lead to health problems, why not change? Despite multiple reasons to change, people don't want to change, the timing is not right, they are afraid to change, or are not motivated to change (Mason & Butler, 2010). Some are afraid because change means facing consequences. For example, "If I quit drinking, I will have to deal with reality," "If I quit smoking, I'll be too nervous/gain weight," or "If I'm not depressed anymore, I will have to go back to work." Others may have failed in the past and are fearful of repeated failure. People who have successfully changed often say getting started is the hardest aspect. For example, in weight loss, denying oneself calories is difficult. But once weight is being lost, the weight loss itself serves as a motivator. A key factor is finding something more significant than the satisfaction one receives from the faulty behavior.
Unfortunately, there is an element of addiction in many faulty health behaviors that makes change even more difficult. The addiction starts innocently, often in the teen years, when the brain is being molded and is chemically vulnerable (Weinberger, Elvevag, & Giedd, 2005). Dopamine, when released in the brain, provides a "feel-good" feedback that then tempts one to seek more of the "temporary fix" (Arias-Carrion & Poppel, 2007). This reward center is powerful, facilitating the love-hate cycle of addiction and poor decision making.
Regrettably, rather than helping patients move toward change, clinicians can make change harder. Healthcare professionals can make and express wrong assumptions about patients that hamper change, such as thinking they need to take a tough approach and scare patients into making a change (Mason & Butler, 2010).Table 1 lists common assumptions clinicians make about behavior change that can interfere with patient motivation to change behaviors. Being aware of patterns can alert clinicians to ineffective interaction styles and suggest more effective methods of thinking and interaction.
An important behavior change principle is that people will change when they are ready, willing, and able. These three elements-readiness, willingness, and ability-illustrate the basic elements of motivation and are components underlying MI.
MOTIVATIONAL INTERVIEWING
MI is a directive, client-centered interaction style that helps patients increase intrinsic motivation toward change. Originally used to treat addiction behaviors, MI has been found to be effective in helping patients with multiple chronic conditions, adherence issues, and lifestyle issues to change their behaviors. MI encourages patients to think about and work toward resolving ambivalence toward change (Miller & Rollnick, 2002). Foundational to MI is the belief that patients are autonomous and healthcare clinicians are collaborators with patients, not dictators. Acceptance of patients where they currently are in the behavior change process is a key concept. Rather than telling patients what to do (authoritarian approach), MI helps them explore their situation, experience, feelings, and capacity for change. The role of the clinician in MI is to listen carefully and encourage exploration by asking questions (Rollnick, Mason, & Butler, 2008).
As an evidence-based practice, MI has been a useful strategy in treating lifestyle problems and diseases. Single studies, systematic reviews, and meta-analyses of randomized controlled trials show that MI outperforms traditional advice giving in the treatment of a broad range of behavioral problems and diseases (Rubak, Sandboek, Lauritzen, & Christensen, 2005). MI has been found helpful in patients with chronic diseases including diabetes, heart failure, asthma, and HIV; and with self-care, adherence, smoking cessation, weight loss, increasing physical activity, decreasing violence, and addressing gambling (Jansink et al., 2009; Rollnick, Butler, Kinnersley, Gregory, & Mash, 2010). Researchers have found that even a brief motivational interaction is more effective than traditional advice giving (Rubak, et al.). It should be noted that because MI works with the patient to explore feelings and heighten awareness, this technique should not be used in patients with suicidal ideation, developmental delays, or cognitive dysfunction (Rollnick et al., 2008).
The process of MI entails (1) expressing empathy, (2) addressing and reducing ambivalence, (3) developing discrepancy, (4) rolling with resistance/avoiding argumentation, and (5) supporting self efficacy (Mason & Butler, 2010; Rollnick et al., 2008). Many of the concepts of MI are consistent with a Christian, biblical perspective. Change and the promise of change are threaded throughout Scripture (Isaiah 65:17; Romans 6:4; 2 Corinthians 5:17), especially for the person who seeks God. For Christian nurses, MI can become a form of ministry to patients.
Expressing Empathy
A key starting place in discussing behavioral change is trying to understand patients' feelings and perspectives about their current situation and the behavior they are trying to change. Use of reflective listening without judging or blaming is imperative, and it is critical to avoid becoming anxious or appearing frustrated to the patient. Christian nurses know a nonjudgmental attitude is important. Jesus instructed, "Do not judge...in the same way you judge others, you will be judged...." (Matthew 7:1-2), and he demonstrated acceptance rather judgment in interactions with people (John 8:3-11). We also are advised to be quick to listen and slow to speak (James 1:19). When listening to patients express why they cannot change a behavior, saying things like, "That must be frustrating" or "I can only imagine how hard this is" can express acceptance. This acknowledgment and acceptance can begin to motivate the change process for patients.
Reducing Ambivalence
Ambivalence is normal. It occurs when there is a conflict between two courses of action: indulgence verses restraint, sometimes referred to as a seesaw: "I want to-I don't want to." A way to help patients become motivated to change is to explore ambivalence (Rollnick et al., 2008). This is done by evaluating the pros and cons of behavior as well as looking at the behavior in the context of the present and the future. In addressing ambivalence, the nurse could ask, "What are some of the good things about smoking? The less good things?" Then ask, "What don't you like about smoking?" and "What would life be like if you didn't (or continue to) smoke?" Finally, summarize the good things and the less good things, helping the patient explore their ambivalence. Using another example, the nurse might ask: "What do you see as a positive thing about your drinking?" Summarization might include: "So, you enjoy relaxing, being out, and drinking with your friends. What are some of the downsides of drinking?"
This process initially may intensify ambivalence about the behavior as the patient explores thoughts and feelings. But eventually exploration can reduce ambivalence by helping patients understand, eliminate, and choose reasons why they want to change behavior. Many patients have never had opportunity to express confusing, contradictory, and uniquely personal aspects of their conflict with negative health behaviors or lifestyle changes. Helping patients identify and verbalize their experience with a behavior can be constructive and increase motivation to change.
Developing Discrepancy
Change can be motivated by a perceived conflict between one's present behavior and important personal goals or values. When this discrepancy becomes large enough, change seems important and begins to occur. The nurse can help patients see their behavior as conflicting with significant personal goals and perhaps increase the importance of change. For example, there may be a discrepancy between where I am now and where I want to be (goals), and who I am versus who I want to be (values).
Ideally, the patient will present reasons for change, not the nurse. Listen carefully for goals and/or values related to the situation and explore the importance of the goal/value. For example, with a patient needing to do painful daily physical therapy exercises, the nurse might hear the patient say, "If my back didn't bother me so much, I could play with my grandkids." The nurse could mention how pain can be reduced through exercise and relate this to the goal of playing with grandchildren. For a diabetic, a goal or value toward managing blood glucose could be to take less medication and/or save money. Note that patients may not know what their goals and values are; listen for these cues or ask good questions to elicit this information.
Rolling With Resistance
A resistant patient may blame, disagree, argue with, minimize, challenge, interrupt, or ignore the nurse. These are our noncompliant patients, those that deny a problem exists, or show resistance through arriving late for appointments or putting off interactions with the nurse. These patients may feel they are being controlled, may try to change the subject, or may refuse to talk. For example, as you try to instruct a patient who smokes, he may argue, "My uncle smoked constantly and he lived to be 90!" It is important not to engage in argument as this leads to defensiveness. We can get the urge to "fix" a person with an obvious fault. Resist this urge as the patient may feel coerced and become defensive. The nurse could respond, "Wow, that's great longevity runs in your family," being careful not offer a "yes, but..." type of response. It is the clinician's position to listen with empathy, accept ambivalence, and encourage/create discrepancy. Research affirms that how a clinician responds to perceived resistance (arguing, stating facts, becoming tense, staying calm, acknowledging feelings) can result in increased or decreased resistance (Hettema, Steele, & Miller, 2005).
Sometimes, behavior that clinicians label as resistance is actually ambivalence. Ambivalence and resistance must be overcome before behavior change takes place. Resistance is a signal for the clinician to respond differently; when necessary, a new direction or momentum may need to be created (Rollnick et al., 2008).
You may be asking, what's wrong with giving advice? Often when patients are ambivalent, clinicians give advice to persuade patients. Although the intentions of giving advice are good, if the individual is not ready or there is ambivalence, he or she may get defensive. For example:
Nurse: Have you thought about reducing the fat in your diet. You should try to avoid fried foods. Your cholesterol and blood pressure are high.
Patient: But the kids won't eat anything that is low fat.
Nurse: Well, high fat foods aren't good for them either.
Patient: Yes, but we can't afford to put food on the table that won't get eaten.
Nurse: Perhaps you could start by eating more fruits and vegetables yourself to set a good example.
Patient: Well, I know I should but....
Supporting Self-Efficacy
Nurses can enhance the patients' belief that they can change by helping them recognize their strengths. The clinician's belief in the patient's ability to change improves outcomes (Gaume, Gmel, & Daeppen, 2008). We read in 1 Thessalonians 5:11 to build others up. Pointing out observations of others' abilities can be helpful, such as, "I see you have dealt with this for a long time. That tells me you're a strong person" or "You have a good handle on this and know a lot about your disease." Ultimately, it is the patient's responsibility to choose and carry out change on their time frame. Motivated clients overcome their own barriers and make their own arguments for change (Rollnick et al., 2008).
INTERVIEWING PHASES
MI occurs in two overall phases. The first phase involves establishing rapport, building trust, and setting the agenda. Partnering with the patient is essential. Miller and Rollnick (2002) refer to this stage as OARS: Open-ended questions, Affirming our patient, continuous Reflective listening, and Summarizing what our patient has said. Traps to avoid in phase one include asking too many questions at once, taking sides on the change decision (treating the change as "best" or the only acceptable decision), and labeling or blaming the patient.
By using open-ended questions, the patient does most of the talking. As we listen, we genuinely affirm the patient's freedom of choice and highlight his or her strengths. Telling a patient, "It sounds like you've really thought a lot about this and have some important ideas" "I appreciate your honesty" or "I see how important this is to you" demonstrates sincerity and builds rapport and trust. Reflective listening deepens the conversation and is more effective than asking multiple questions. Nurses can use double-sided reflection, saying things like, "It sounds like..." "Help me understand, on one hand you tell me trying to stick to a specific plan seems daunting and on the other hand you think your self-esteem would improve if you followed through with this." Another tool is the use of amplified reflection. If a patient says, "All of my friends drink and I don't see myself giving it up," the nurse can respond "So, you think you and your friends will keep drinking forever?" To summarize, you might say "Let me see if I understand what you have told me."
To get a dialog started, the nurse could use questions such as: "Tell me about your situation?" "What do you know about ____?" "What are your concerns about ____?" "How did you first start ____?" Health behaviors frequently relate to deeper issues, and ambivalence and resistance are natural barriers to change. It is important to elicit the patient's viewpoint and explore reasons for and against change, remembering that responsibility for change resides with the person who must decide if, when, and how change will occur using his or her own resources.
Phase two of MI involves addressing readiness and commitment to change, and enhancing motivation. Importance and confidence should be continually assessed. Keep in mind change usually is nonlinear and readiness is not static; it can be more effective to help patients aim for small changes and not perfection. Change is a process and usually not "all or nothing."
Motivation varies and knowledge alone is insufficient to change. Relapse is common. Key factors for recognizing readiness include diminished resistance, questions about change, envisioning, experimenting, and talking about commitment to change (Rollnick, Miller, & Butler, 2008).
One helpful tool in MI is the use of "rulers" or scales assessing the importance of change to patients, their confidence about changing, and readiness for change (Rollnick, Mason, & Butler, 2005). To assess importance, the nurse could ask, "On a scale of 0 to 10 where 0 is the least and 10 the most, what number would you give for how important it is for you to (behavior change) right now?" To assess confidence, patients could be asked, "On a scale of 0 to 10 where 0 is least and 10 most, what number would you give for how confident are you that you could (behavior change) if it were important to you?" Finally, readiness could be assessed in a similar fashion. For additional exploration, the nurse could ask why the number isn't higher and then why it isn't lower. This helps the patient explore and can bring a deeper perspective about issues that affect change. It's important to leave the door open for further discussion and exploration. If a patient is not ready to change, the nurse could say, "It seems you don't feel ready to talk about this. If you want to talk further please feel free to come and see me."
The patient's strength of commitment to change is critical to success. The more commitment language verbalized by the patient, the stronger their commitment becomes toward change (Amrhein, Miller, Yahna, Palmer, & Fulcher, 2003). Paying attention to commitment language can be helpful. D.A.R.N. is an acronym explaining underlying motivational dimensions addressed in phase 2 and offers cues for what to listen for in commitment to change: (1) Desire: "I want to change," (2) Ability: "I can do it," (3) Reasons: "This will affect my health," and (4) Need: "I must do it" (Miller & Rollnick, 2004).
STAGES OF CHANGE
The Transtheoretical Model of Change illustrates stages of change, explaining how people change (but not why) (Miller & Rollnick, 2009; Prochaska, Norcross, & DiClemente, 1995). In the precontemplation stage, the individual has no intention or desire to change or is uninformed of the consequences of the behavior. This is a frustrating stage that some patients never get beyond. The nurse's position is to increase awareness and create discrepancy. In the contemplation stage, the individual intends to take action to change soon (the next 6 months), but is not quite ready. He is aware of the benefits, is ambivalent, and is usually aware of the difficulties the current behavior is causing. The clinician can evoke reasons for change, strengthen self-efficacy, and normalize ambivalence. About two-thirds of patients seen in primary care are in the precontemplative and contemplative stages (Simon, Flynn, & Flocke, 2007).
In the preparation stage, the patient intends to take action, perhaps in the next month. She or he may have taken some behavioral steps necessary for change and may have a plan of action. While in the action stage, the patient may make small behavioral changes, and is considering longer-term options and making commitments. During this transition, the benefits seem to outweigh the costs. Goals are becoming important and discrepancies are being examined. It is important to make the patient aware of the benefits/consequences, affirm the patient, explore outcome expectancies, and elicit what has worked in the past. In the action stage, the individual is making or has made a recent behavior change (past 6 months). Offer praise, reinforcement, and ask questions like, "What is giving you success right now in making this change?"
Finally, in the maintenance stage, the individual has stopped the unwanted behavior for more than 6 months. They are confident things are going well and working to prevent relapse. The nurse's position is to address relapse issues and reinforce benefits of continued change. As a rule, behavior change is easier to maintain over time but temptation plays a significant role. If one is not tempted at this stage, this is not the norm. Christian patients can remember God understands and wants to help us with temptation (1 Corinthians 10:13; Hebrews 4:14-16).
During the maintenance stage, the changes clients have made are being integrated into their definition of who they are and what their life is like without the overt behavior. If a setback occurs, we must emphasize this is not failure, and remind them that change is a process, both fluid and uneven. Continued trust enables people to discuss failure and moving beyond. For Christians, remembering "I can do all things through Christ, who strengthens me" (Philippians 4:13) can be encouraging. Relapse can be an additional stage of change. Encourage patients this is normal and help them rethink their original reasons for changing.
A SMART PLAN
As ambivalence moves toward motivation and commitment to change, the development of a change plan can be initiated. The S.M.A.R.T. plan is a brief motivational tool that can assist nurses and patients in developing behavioral change plans (Miller, 1999).
S pecific: What is the specific goal? I want to lose 15 lbs, starting with 2 lbs.
M easurable: How will success be defined? 2 lbs, 7000 calories, and record it.
A chievable: What resources are available to be successful; what is the level of confidence? Adjust goals as needed.
R ealistic: How reasonable is the plan? Begin at patient's level of comfort, set goals accordingly.
T ime frame: What is the time frame for each step? Set incremental time frames; lose 2 lbs. in 2 weeks.
Rewarding small successes makes changes worthwhile. It may be helpful to write specific recommendations for each step of the plan. For some, bringing prayer and/or Scripture into the plan can be appreciated, such as "Our steps are made firm by the LORD, though we stumble, we shall not fall headlong, for the LORD holds us by the hand" (Psalm 37:23-24, NRSV). It is important to not overestimate the patient's readiness to change as this often leads to resistant behavior. Interventions must be matched to the appropriate stage of change.
CONCLUSION
In MI, we meet patients where they are without expectations or demands. We understand that ambivalence is normal. MI involves exploring the good and not so good, recognizing and reducing resistance, addressing readiness, importance, and goals with patients. We continually attempt to build confidence and keep the door open for listening, exploration, and possible change. Clinicians typically only have brief periods with patients and MI techniques can help us make the most of this time. Christian nurses can prayerfully ask for wisdom (James 1:5) and guidance from the Holy Spirit.
Courses are offered worldwide by the Motivational Interviewing Network of Trainers (2010) to introduce and train clinicians in techniques of MI. Nurses and other clinicians regularly involved in helping patients change behaviors should seek professional training to become effective in MI. Miller and Moyer (2006) describe an eight-stage process of learning MI beginning with openness to collaboration with the patient and ends with learning flexibility and being able to switch between MI and other interview styles. Using MI, nurses can be God's instruments to minister to patients, extending God's unconditional love and hope that changes behavior and hearts.
Web Resources
* Motivational Interviewing-http://motivationalinterviewing.org/
* YouTube-http://www.youtube.com (search "motivational interviewing")