Motivational Interview Strategies In Nursing Education by Miller and Rollnick
Motivational Interview Principle by Miller & Rollnick
The five general principles of MI (Miller & Rollnick, 2013) are arranged to form the mnemonic READS, which helps nurses remember the key concepts of this approach. The following principles are not applied in a specific order, and all the techniques should be used through- out the interview:
1. Roll with resistance
2. Express empathy
3. Avoid argumentation
4. Develop discrepancy
5. Support self efficacy
Rolling with resistance refers to a strategy of acknowledging to the patient that ambivalence is natural and, rather than oppose the resistance, the nurse “rolls” or flows with it. Resistance is expected and should not be viewed as a negative occurrence by the nurse.
It can take several forms, including blaming, excusing, minimizing, arguing, challenging, interrupting, and ignoring. When the patient displays resistance, the nurse should actively involve the patient in the process of problem solving and attempt to explore the reasons behind the resistance.
Expressing empathy communicates to patients that they are understood and they are accepted as they are and where they are, which helps to facilitate change. As part of this technique, it is important that the nurse not judge, criticize, or blame the patient. Specifically, the nurse needs to employ excellent active and reflective listening skills throughout the interview to establish a therapeutic rapport.
Avoiding arguments decreases instances of confrontation, which usually make patients feel defensive. Defensiveness often leads to further resistance rather than instilling motivation for change. When the urge to argue arises, the nurse should instead change strategies to help the patient self-identify important issues and problem areas
Developing discrepancy involves helping patients understand how their current behavior is inconsistent with their personal goals and/or values. This realization acts as a source of motivation for change by the patient. The objective is for patients, rather than the nurse, to identify why change is necessary after seeing the inconsistencies between their behaviors and their goals.
Supporting self efficacy involves building the patient’s confidence that change is possible. The nurse can do this by providing support and recognition for small steps the patient has made toward his or her goals, helping the patient set reachable goals, and demonstrating belief in the patient’s ability to succeed.
OARS Mnemonic of Miller & Rollnick Strategy
In addition, the MI approach includes specific strategies that the nurse can use for building motivation to change in the early phases of treatment and continuing throughout the treatment. Miller and Rollnick (2013) suggest the mnemonic OARS to describe these strategies
1. Open-ended questioning
2. Affirmations of the positives
3. Reflective listening
4. Summaries of the interactions
Open ended questions facilitate discussion between nurse and patient and encourage the patient to do most of the talking, particularly about the reasons why change is necessary or desirable. To encourage a patient centered dialogue, the nurse should avoid closed-ended questions for which a simple “yes” or “no” answer could limit further discussion (Levensky, Forcehimes, O’Donohue, & Beitz, 2007).
Affirming the positives involves the nurse making statements that support and encourage the patient, particularly in areas where the patient may see only failure. Affirmations can take the form of complimenting efforts made by the patient, acknowledging small successes, or stating appreciation and understanding (Levensky et al., 2007). This approach promotes self-efficacy, builds rapport, and reinforces the efforts the patient is making toward change.
Reflective listening involves restating the patient’s own comments in a concise manner, which demonstrates that the nurse understands what the patient is saying. The goal of this technique is to keep the conversation moving forward so the patient can see the need for change and begin to move in that direction.
Summarizing links and reinforces the information that has been discussed. It helps to build rapport with patients and demonstrates that the nurse has heard the patient. Summaries are important ways to emphasize significant parts of the discussion and to review the plan of action.
A growing body of literature explores the use of MI in health care. MI is being applied in a broad range of behavioral issues, including those related to alcohol abuse (Beckham, 2007), bipolar disorder (Laakso, 2012), cancer pain (Thomas et al., 2012), cardiovascular disease (Brodie, Inoue, & Shaw, 2008; Hardcastle, Taylor, Bailey, & Castle, 2008; Paradis, Cossette, Frasure-Smith, Heppell, & Guertin, 2010; Thompson et al., 2011), chronic kidney disease(McCarley, 2009), colorectal screening (Corey, Gorsky, Schaper, & Newberry, 2009), depression (Interian, Rios, Martinez, Krejci, & Guarnaccia, 2010, Watkins et al., 2007), diabetes (Chen, Creedy. Lin, & Wollin, 2011; Huisman & de Gucht, 2009; Wang et al., 2010), obesity (Carels et al., 2007; Schelling et al., 2009), schizophrenia (Drymalski & Campbell, 2009, Tay, 2007), stroke education (Byers, Lamanna, & Rosenberg, 2010), to- bacco use disorders (Borrelli et al., 2005; Stotts, DeLaune, Schmitz, & Grabowski, 2004), and low back pain (Friedrich, Gittler, Arendasy, & Friedrich, 2005; Vong, Cheing. Chan, So, & Chan, 2011).
Most of the current evidence related to MI use comes primarily from studies with adults, but this technique may be particularly useful with the adolescent population because its collaborative, nonconfrontational approach fits well with the developmental need for identity and autonomy that characterizes this stage of growth (Jackman, 2011).
Although study outcomes for MI are some- times inconsistent, several systematic reviews as well as meta-analysis reports reveal quite a few statistically significant results for the use of MI in the healthcare arena (Hettema, Steele, & Miller, 2005; Lundahl, Kunz. Brownell, Tollefson, & Burke, 2010; Lundahl et al., 2013; Martins & McNeil, 2009; O’Halloran et al., 2014: Rubak. Sandback, Lauritzen, & Christensen, 2005; Van Buskirk & Wetherell, 2014).
Martins and Mc Neil (2009) suggested that MI is effective in diet and exercise, diabetes, and oral care. O’Halloran et al. (2014) revealed MI with people who have chronic illnesses was a useful strategy in increasing their physical activity levels.
VanBuskirk and Wetherell (2014) discovered that MI can be applied to primary care populations. In a review of 72 MI studies, Hettema et al. (2005) uncovered small to medium effects for MI in improving health outcomes and found it to be a promising intervention in addressing addictive behaviors (except for smoking cessation).
Lundahl et al. (2010) performed a meta analysis of 25 years of MI interviewing studies, and their analyses strongly suggested that “MI exerts small, though significant, positive health Behaviors of the Learner effects across a wide range of problem domains, although it is more potent in some situations compared to others and it does not work in all cases” (p. 151).
These authors also found that MI significantly increased patients’ engagement in treatment and their intention to change, and when MI was compared to other active treatments, the MI interventions took at least 100 fewer minutes of treatment on average yet produced equal effects (Lundahl et al., 2010).
Also, another major study found as few as one MI session may be effective in enhancing readiness to change behaviors to reach health goals (VanBuskirk & Wetherell, 2014). These are particularly significant findings given that nurses have only a limited amount of time to spend with patients and need to be as efficient as possible in their interactions with patients.
Rubak et al. (2005), in their own meta-analysis of MI, reported that “motivational interviewing in a scientific setting effectively helps clients change their behavior and it out performs traditional advice giving in approximately 80% of the studies” (p. 309).
Their review also showed that MI can be effective even in brief encounters of 15 minutes and that more than one encounter increases the likelihood of effect. All reviews suggest the need for further research into MI using improved research methodologies.
MI can be a useful tool for helping nurses as educators achieve success in one of their major roles namely assisting patients to change negative health behaviors. Nurses need to exercise patience when learning MI, however, because this approach requires them to adjust to a new way of thinking. They need to be open minded and willing to let go of the tendency to give ad- vice and offer expert opinions (Brobeck, Bergh, Odencrants, & Hildingh, 2011; Soderlund et al., 2008).
With time and practice, nurses will also be able to let go of the “righting reflex,” which is the tendency to identify a problem and solve it for the patient (Rollnick et al., 2010; Rollnick, Miller, & Butler, 2008). Instead, they ideally will use MI to empower and motivate patients to do the work themselves.
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