Background

Adolescents - defined as young people between 10 and 19 years of age1 - are, in general, a relatively healthy segment of the population.2 However, the developmental changes that take place during adolescence may affect their subsequent risk for diseases and a variety of health-related behaviors. In fact, early onset of preventable health problems (e.g. obesity, malnutrition and STDs) and the engagement in health-risk behaviors (e.g. sedentary life style, excessive alcohol consumption and unprotected sex) during adolescence are likely to put them at greater risk of physical and mental health problems at a later stage in life. Moreover, health-related problems and health-risk behaviors may disrupt adolescents' physical and cognitive development and therefore may affect their ability to think and act in relation to decisions about their health in the future.1 In summary, health-related behaviors in adolescence, apart from their influence on the continuum of "health-disease", also have the potential to influence future behaviors. In fact, several studies have shown that past behaviors are good predictors of future behaviors.3,4 Thus, promoting healthy practices during adolescence and taking measures to better protect young people from health risks are essential for the prevention of health problems in adulthood.5

According to the World Health Organization, the main problems affecting young people include mental health problems (such as behavioral disorders, eating disorders, suicide, anxiety or depression), the use of substances (illegal substances, alcohol and tobacco), interpersonal violence, nutrition (a proper nutrition consists of healthy eating habits and physical exercise), unintentional injuries (which are a leading cause of death and disability among young people, with road traffic injuries accounting for about 700 deaths per day), sexual and reproductive health (e.g. risky sexual behaviors, early pregnancy and childbirth) and human immunodeficiency virus (resulting from sexual transmission and drug injection).5,6 On the other hand, the number of children and youth with chronic health conditions has increased dramatically in the past four decades7 as a larger number of chronically ill children survive beyond the age of 10.8 Despite the lack of data on adolescents' health making it difficult to determine the prevalence of chronic illnesses in this age group,9 it is known that one in 10 adolescents suffers from a chronic condition worldwide.10 In fact, national population based studies from Western countries show that 20-30% of teenagers have a chronic illness, defined as one that lasts longer than six months.8 The most prevalent chronic illness among adolescents is asthma and the one with the highest incidence is diabetes mellitus, particularly type II.9

Traditionally, healthcare professionals have been mainly investing in health education activities, through the transmission of knowledge with a view to creating habits, customs and behaviors, and promoting healthy lifestyles. However, empowering people does not only consist of giving them the right information,11 that is, good information is not enough to cause people to make changes.12 The motivation or desire to change unhealthy behaviors and habits depends on many factors, namely intrinsic motivation, control over personal decisions, self-confidence and perception of effectiveness, personal ambivalence, and individualized assistance.12 Many professionals assume that supplying knowledge is sufficient for behavioral changes; however, even very good advice often fails to generate behavioral change. After all, people continue to engage in unhealthy behaviors despite clearly knowing what they should do and how to change. "What is lacking is the motivation to apply that knowledge".13^(p.1233)

In fact, behavioral change is a complex phenomenon with multiple determinants that also includes motivational variables. It is associated with ambivalent processes expressed in the dilemma between keeping the current status and moving on to new ways of acting. For example, telling adolescents that if they keep on engaging in a certain behavior, they are increasing the risk of developing a long-term condition such as cardiovascular disease, stroke or diabetes is rarely enough to trigger the desired behavioral change; people are more likely to change when they believe that the change is really effective and that they are able to implement it.12 Therefore, it is essential to provide specific training for healthcare professionals to master motivational techniques, avoid confrontation with the users, and facilitate behavioral changes.14

In this context, motivating patients to make behavioral changes is also an important nursing task where change in lifestyle is a major element of patients' treatment and preventive interventions.15 One of the nurses' goals is to help improve patients' health or help them to manage existing health conditions. Once nurses are in a position where they have to focus on accomplishing tasks and telling patients what needs to be accomplished,16 the role of the nurse is expanding even more into the use of motivational strategies.17 Motivational interview (MI) is bringing nurses back to therapeutic communication and moving them closer to successful health promotion and disease management, by promoting behavior change and empowering their patients. As the nursing profession evolves, MI is seen as a challenge and the basis of nurse's interactions with individuals, families and communities.16,17

In the same way, MI may be taken as an essential tool in the provision of nursing care to adolescents, being itself a workspace with possible therapeutic effects regarding problems, clarification of doubts and development of skills.18 In fact, MI may be particularly applicable in work with adolescents because of their specific developmental stage. Adolescents attempt to establish their own autonomy and identity while struggling with social interactions and moral issues, that leads to ambivalence.19 Consistent with the developmental challenges during adolescence, "MI explicitly honors autonomy, people's right and irrevocable ability to decide about their own behavior"20 while allowing the person to explore possibilities for change of risky or maladaptive behaviors.19^(p.136)

Motivational interviews can be defined as a directive, client-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence. It is most centrally defined not by technique but by its spirit as a facilitative style of interpersonal relationship.21 It is a set of strategies and techniques widely used in clinical practice based on the trans-theoretical model of change. The Stages of Change model describes five stages of readiness - precontemplation, contemplation, preparation, action and maintenance - and provides a framework for understanding behavioral change.22 The MI has been widely tested and applied in different areas, such as modification of addictive behaviors, interventions with offenders in the context of justice, eating disorders, promotion of therapeutic adherence among chronic patients, promotion of learning in school settings or intervention with adolescents at risk.18,23

In general, clinical practice has been adopting the perspective of motivation as something relatively immutable, that is, the adolescent is either motivated for change/treatment and, in these conditions, the professional's role is to help him/her, or the adolescent is not motivated and then change/treatment is not feasible. Alternatively, the theoretical model underlying the MI technique postulates that the individual's adherence to change/treatment depends on his/her motivation, which can change throughout the therapeutic intervention. As several studies found positive results for effects of MI24-26 and its use by health professionals is encouraged,23,27 nurses may play an important role in patients' process of change. As nurses have a crucial role in the clinical context, they can facilitate the process of ending risk behaviors and/or adopting positive health behaviors through some motivational techniques, namely with adolescents.

A considerable number of systematic reviews about MI already exist, pointing to some benefits of its use in the treatment of a broad range of behavioral problems and diseases.13,28,29 Some of the current reviews focus on examining the effectiveness of MI for adolescents with diverse health risks/problems.30-32 However, to date there are no reviews that present and assess the evidence for the use of nurse-led MI in adolescents. Therefore, we have little knowledge of what works for whom (which adolescent subpopulation) under what circumstances (in which setting, for what problem) in relation to MI by nurses. There is a clear need for scoping or mapping the use of MI by nurses with adolescents to identify evidence gaps and to inform opportunities for future development in nursing practice.

On the other hand, information regarding nurse-led implemented and evaluated interventions, techniques and/or strategies used, contexts of application and adolescents subpopulation groups is dispersed in the literature33-36 which impedes the formulation of precise questions about the effectiveness of those interventions conducted by nurses and therefore the realization of a systematic review. In other words, it is known that different kinds of motivational interventions have been implemented in different contexts by nurses; however, does not exist, a map about all the motivational techniques and/or strategies used. Furthermore, the literature does not clarify which is the role of nurses at cross-professional motivational intervention implemented programs and finally the outcomes and evaluation of interventions are unclear.

Thus, the practical implication of this mapping will be clarifying all these aspects. Without this clarification, it is not possible to proceed to the realization of a systematic review about the effectiveness of the use of MIs by nurses to promote health behaviors in adolescents, in a particular context and/or health-risk behavior, or regarding the effectiveness of certain technique and/or strategy of MI. Consequently, there are important questions about the nature of the evidence in this area that need to be answered before formulating a precise question of effectiveness. This scoping review aims to respond to these questions.

An initial search of the JBI Database of Systematic Reviews and Implementation Reports, Cochrane Database of Systematic Reviews, Database of Promoting Health Effectiveness Reviews (DoPHER), The Campbell Library, Medline and CINAHL, has revealed that currently there is no scoping review (published or in progress) on the subject.

In this context, this scoping review will examine and map the published and unpublished research around the use of MI by nurses implemented and evaluated to promote health behaviors in adolescents; to establish its current extent, range and nature and identify its feasibility, outcomes and gaps in the evidence defining research priorities in this field. This scoping review will be informed by JBI methodology37 that suggests a five-stage methodological framework for conducting scoping reviews that includes identifying the research question, searching for relevant studies, selecting studies, charting data, collating, summarizing and reporting the results.

Inclusion criteria

Types of participants

This scoping review will consider all research studies that focus on adolescents aged 10-19 years and participating in MIs conducted by nurses.

Concepts

This scoping review will consider all research studies that address MIs conducted by nurses to promote healthy behaviors or health behavior change.

The concept shall be grounded in but not limited to MI principles laid down by Miller and Rollnick.21 To qualify as MI for the purposes of this review, the therapeutic intervention may be referred to as "motivational interviewing", "motivational enhancement", "motivational enhancement therapy", "motivational intervention", "brief intervention" or "brief motivational intervention" as Miler and Rollnick23 accepted these variations of the concept equally valid as long as practitioners use rapport strategies to help the patient explore and resolve ambivalence about change. There are five guiding principles in conducting motivational interviews: "expressing empathy", "developing discrepancies", "avoiding argument", "roll with resistance", and "support self-efficacy". In addition, basic therapeutic skills are often used in the interview process, including reflective listening, asking open questions, affirming, weight of cons and pros, summarizing and elicit self-motivational statements. So, it will be considered for inclusion interventions that make reference to all or partial mentioned principles and skills of MI. As MI is based at the trans-theoretical model, studies with interventions tailored accordingly the practice guidelines for the stages of Change22 will also be accepted. The intervention can be delivered on an individual basis or as group sessions, with any number of sessions, face-to-face or telephone-based interview, as a stand-alone therapy or combined with other non-motivational interventions.

The term "Promote health behaviors" reports to actions taken to maintain, attain or regain good health and wellbeing and to prevent illness. So, it will include:

* The promotion of positive health behaviors that convey health benefits or otherwise protect individuals from disease (i.e. exercise, healthy diet, condom use, regular check-ups, [horizontal ellipsis])

* The prevention of health-risk behaviors that have harmful effects on health or otherwise predispose individuals to disease. (i.e. smoking, excessive alcohol or drugs consumption, eating disorders and sedentary)

Context

This scoping review will consider all contexts where nurses' may undertake MI with adolescents including, but not limited to, clinical practice contexts such as hospitals, primary health care, healthcare centers, as well as community or school contexts. All geographical contexts will be contemplated.

Types of sources

This scoping review will consider any existing primary research studies, quantitative or qualitative design and also systematic reviews, including meta-analysis and meta-syntheses. If duplicated data resulting from primary studies and systematic reviews is found, it will be discussed, analyzed and reported.

Quantitative designs include any experimental study designs (including randomized controlled trials, non-randomized controlled trials, or other quasi-experimental studies, including before and after studies), and observational designs (descriptive studies, cohort studies, cross sectional studies, case studies and case series studies). Cost-effectiveness studies are also included.

Qualitative designs include any studies that focus on qualitative data such as, but not limited to, phenomenology, grounded theory and ethnography designs.

Search strategy

The search strategy aims to find both published and unpublished studies. A three-step search strategy will be utilized in this review. An initial limited search of MEDLINE and CINAHL will be undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Third, the reference list of all identified reports and articles will be searched for additional studies. Studies published in English, Spanish and Portuguese will be considered for inclusion in this review. As the concept of MI was first described by Miller in 1983,38 studies published since that year until the date of the search will be considered for inclusion in this review to add to an understanding of how the MI implemented and evaluated by nurses to promote health behaviors on adolescents has been researched and understood over time.

The databases to be searched include:

CINAHL

Psychology and Behavioral Sciences Collection

Academic Search Complete

PubMed

Cochrane Central Register of Controlled Trials

LILACS

Scopus

Library, Information Science & Technology Abstracts Scielo - Scientific Electronic Library Online

PsycINFO

Cochrane Database of Systematic Reviews

The search for unpublished studies will include:

ProQuest - Nursing and Allied Health Source Dissertations

Banco de teses da CAPES (Brasil)

RCAAP - Repositorio Cientifico de Acesso Aberto de Portugal

OpenGrey - System for Information on Grey Literature in Europe

The initial English language search string will be developed to contain Boolean combinations related to motivational interview*, motivational intervention*, motivational enhancement*, motivational enhancement therap*, motivational counsel*, brief intervention* (combined by OR) to adolescen*, teen*, young* (combined by OR) and to nurs*. The three components of the search around MI, adolescents and nursing will be combined by AND. In addition, key concepts related to MI such as 'stages of change' and 'transtheoretical model' may be included to ensure articles not explicitly advertising the use of MI would be included.

Articles identified from the search will then be assessed for relevance to the review, based on the information provided in the title and abstract, by two independent reviewers. The full article will be retrieved for all studies that meet the inclusion criteria of the review. If the relevance of a study is unclear from the abstract, the full article will be retrieved.

Based on full texts, two reviewers will examine independently whether the studies conform to the inclusion criteria. Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer.

Studies identified from reference list searches will be assessed for relevance based on the study's title and abstract.

Extracting the results

Quantitative and qualitative data will be extracted from articles included in the review using a charting table that aligns to the objective and question of this research (Appendix I) as indicated by the methodology for scoping reviews proposed by Joanna Briggs Institute.37

Two reviewers will extract data independently. Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer.

In this point the two reviewers, independently of one another, will chart the first five to 10 studies using the data-charting form and meet to determine whether their approach to data extraction is consistent with the research question and purpose. In addition, if it is necessary, primary authors will be contacted for further information/clarification of the data, as suggested by Joanna Briggs Institute.37

Presenting the results

The overview of the reviewed material will, wherever possible and appropriate, be presented in a tabular summary (Appendix II) with the aid of narrative and figures.

Moreover, the tables and charts will show the following data: MI type, duration of the intervention, year of publication, country of origin, characteristics of study population, methodology adopted and outcomes and details of these.

The narrative analysis, made by categories, will describe the aims of the studies and the results related to the review questions.

Acknowledgements

The authors thank the support provided by Health Sciences Research Unit: Nursing (UICISA: E), hosted by the Nursing School of Coimbra (ESEnfC).

Appendix I: Data extraction instrument

Appendix II: Results extraction instrument

References