Motivational interviewing: A communication best practice

Author(s): Debbie Bershad, BSN, RN, CHPN

This collaborative approach can influence behavior change and improve healthcare literacy.

Takeaways: 

  • Motivational interviewing (MI) is collaborative conversation style that promotes positive health behavior change and strengthens an individual’s motivation and commitment to change.
  • MI uses the OARS mnemonic (Open-ended questions, Affirmation, Reflective listening, and Summarizing)

RESEARCH has shown that 60% of the factors that affect the risk of premature death can be attributed to individual health behaviors (40%) and social and environmental factors (20%). One way that nurses can influence these behaviors and factors is through motivational interviewing (MI). This collaborative conversation style designed by Miller and Rollnick promotes positive health behavior change and strengthens an individual’s motivation and commitment to change.

MI benefits

MI is an evidence-based method of therapeutic communication that helps patients better understand and use their personal resources to identify, create, implement, and sustain positive change in health behaviors and decisions; it offers benefits to patients and nurses. Even with varying levels of MI proficiency and with very little extra time to spend with patients, nurses can see positive patient outcomes.

Good patient relationships are built on collaboration, mutual trust, and respect. Time pressure is a significant issue for nurses, and MI allows you to use your time more effectively when providing patient education and reinforcing compassionate care. MI also can help enhance patient satisfaction with healthcare provider relationships, increase healthcare literacy, and improve health outcomes.

Integrating MI into day-to-day interactions with patients can reduce stress in patient and nurse-to-team member interactions, improve patient-centered care delivery, and enhance nurse satisfaction.

Communication change

For some nurses, MI represents a fundamentally different way of communicating and interacting with patients. It makes communication part of “being” with patients and helps you quickly establish a nonjudgmental relationship and create an environment where sensitive information or a lack of knowledge can be disclosed, and a more informed plan of care can be developed.

Many of us have been trained to direct patients in their health behaviors and practices. MI helps you collaboratively build and guide patient relationships, positively influence their healthcare behaviors and choices, and gain better insight into the social and environmental factors that impact those choices. When adult learners know the rationale and personal relevance for change, it’s easier to teach and support that change when the patient is ready. MI facilitates that process.

MI framework

Ineffective or inadequate communication remains a root cause of nurse-nurse and nurse-patient/family stress. MI is built on open, respectful, and compassionate communication. It can enhance nurse communication effectiveness, whether you’re a novice or a seasoned nurse. (See 6 steps to MI integration.)

The acronym OARS provides a framework to begin implementing MI into your day-to-day interactions with patients.

Open-ended questions. Typically, these questions start with “who,” “what,” “when,” “where,” and (with careful application) “why.” “Why” questions can seem judgmental, invite defensiveness, and, in most instances, should be avoided. An alternative to asking “why” is to insert the phrase, “Tell me about…” to nonjudgmentally encourage disclosure. Instead of asking “Why did you start using opiates excessively,” say, “Tell me about your experience with opiates.” If a “why” question is used, consider asking “Why did that feel important to you?” instead of the less effective “Why did you do that?”

Affirmation. When talking with the patient, listen for and remember examples of good decision-making, health management, and behavior change that you can affirm later. Consider, for example, a patient who’s having trouble remembering when to take his medications. When he tells you that his daughter has made a list of his medications and the correct times to take them in a large, easy-to-read font, you can affirm this by saying, “That is a great way to help visually remind you when to take your medications. I agree with your idea of taping that list on a kitchen cabinet, close to where you keep your medications to help you remember when to take them.”

Reflective listening. Every conversation has times to question and times to listen. Listening is frequently the most difficult part of MI to implement, so use your nursing skills to listen carefully and intuitively. Intuition helps you pull out the most important parts of a conversation that often go unsaid but, once said, add significant meaning and understanding. For example, when a nurse was speaking with a patient about possible neglect in a skilled nursing facility, the patient abruptly asked the nurse to leave and come back another day. The nurse’s initial response was to follow the patient’s request, but her intuition told her there was more to the situation. She said she would come back the next day and then added: “You have something to tell me tomorrow.” The patient eagerly responded, “Yes, I absolutely want to talk with you tomorrow.” The follow-up investigation revealed deficiencies in quality of care for this patient.

Reflective listening can be as simple as turning a question into a statement. For example, “You’re feeling hopeless” rather than, “Are you feeling hopeless?” This strategy allows you to check in with the patient in a nonthreatening way to uncover deeper meaning and to encourage healthy self-awareness—a critical first step in the process of changing health behaviors.

In more advanced applications of reflective listening, you can reframe and summarize what the patient has said; however, don’t simply repeat it. For instance, a patient on hospice refused to take the morphine prescribed to address her nocturnal dyspnea. The patient told the visiting nurse about a recent emergency department visit where she was diagnosed with a transient ischemic attack. She said that during the experience she felt light-headed and her thinking became fuzzy. The nurse reframed and summarized what she heard the patient say: “It sounds like that was frightening and that your body’s response to the morphine may be similar to what you experienced in the emergency department.” Summarizing and reframing affirmed the patient’s experience and allowed the nurse to provide education about the benefits of morphine to manage the nocturnal dyspnea.

Summarize and teach-back. Summarize any strengths the patient has shared, as well as action steps that have been discussed. To ease into summarizing, say something like “Tell me about your plans” or ask, “What else will you do?” Build on the expectation that the patient can focus on, remember, and follow through with the plan. Summarizing also helps identify and address gaps in knowledge and serves as a reminder of follow-up responsibilities.

Also consider asking the patient to teach back what he or she is going to do. The teach-back method promotes healthcare literacy by reinforcing key learning concepts and providing an opportunity to correct any misunderstandings. To help counter concerns that the patient may become defensive when being asked to repeat information, make it about you. For example, you can say, “To make sure I’ve done my job of explaining this to you, please show me what you’re going to do when changing this dressing.”

As with any new skill, practice and seek feedback from other nurses or team members so you can improve your proficiency and build confidence. As you become more competent at asking open-ended questions, affirming your patients, actively and reflectively listening, and summarizing patients’ plan of action, you’re engaging with them respectfully and compassionately.

MI’s future

Based on experience and literature reviews, the time is ripe for more MI nursing research. We need to know if MI impacts the delivery of patient-centered and compassionate care and if it contributes to patients’ healthcare literacy. We also need to learn if patient satisfaction increases when MI techniques are used and if nursing students experience less stress and engage more effectively with patients when using MI.

But you don’t have to wait for more research before putting the positive effects of MI into action. Begin by placing a focus on integrating MI into your daily nursing routine, as you support and encourage nursing research that will answer questions important to patients and nurses.

Debbie Bershad is a nursing professional development consultant at 360 HealthPartners in Novato, California.

Selected references

Agency for Healthcare Research and Quality. The SHARE approach— Using the teach-back technique: A reference guide for health care providers. July 2014. ahrq.gov/professionals/education/curriculum-tools/shareddecisionmaking/tools/tool-6/index.html

Miller WR, Rollnick S. Motivational Interviewing: Helping People Change. 3rd ed. New York City, NY: Guilford Press; 2013.

Schroder SA. We can do better—Improving the health of the American people. N Engl J Med. 2007;357:1221-8.

U.S. Department of Health & Human Services. America’s health literacy: Why we need accessible health information. 2008. health.gov/communication/literacy/issuebrief

6 COMMENTS

  1. Ms. Bershad, Your statement, “MI also can help enhance patient satisfaction with healthcare provider relationships, increase healthcare literacy, and improve health outcomes” is so pertinent in enhancing the patient experience, one of three essential parts to the Three Part Aim for the National Quality Strategy. The other two, Population and Cost per capita provide a model for understanding the level of commitment and manner of attention for a given population. I believe the MI method, with its essential points, builds a bond. Then to, healthcare literacy is a primary reason patients misunderstand what is happening in the care milieu. With a few calm minutes that the nurse utilizes plain language in a manner preferred by the patient, everybody wins and health outcomes are perceived as met or improved. Thank you for sharing this article with us.

    • Ms. Brown,
      Thank you for sharing your insight and perspective. To elaborate a bit as to how the nurse wins, the ability to more quickly build a mutual bond of trust and respect has the potential to add meaning, satisfaction and resilience to the nurse’s role. This is true in many patient care delivery systems, as there is a constant time pressure and list of tasks to be completed on a constant and daily basis.
      As nurses build their communication skills, it is important to always remember to use those skills both for the benefit of nurse and patient, then too, everyone (organizations included) wins.

  2. As a communication style, the use of MI can only make a nurse’s life easier and a patient’s life better. While the process takes time to learn, it will ultimately save time and stress. And the transfer of these skills to other interpersonal relationships is a natural – again, leading to decreased stress and more effective conflict resolution. Thanks for the article, thanks for your work and bravo to nurses everywhere!

  3. Dr. Miller,
    Thank you for sharing your observations, your dedication to research and for your advocacy of scientific inquiry. I am interested in research into the role MI plays in the patient/caregiver experience in all nursing settings, as well as hearing from those nurses who have consistently utilized the modality.

  4. I have an additional curiosity after 35 years of research and development with motivational interviewing: How does learning and using this method affect the provider’s own experience in practice, or life experience more broadly? Often people at workshops tell me how MI has changed their life, and I’d like to understand better what that means – what has actually changed and why. It seems related to satisfaction with one’s work, diminished stress, increased engagement with patients, personal peacefulness.

  5. I hope that those of you who are experiencing success in applying Motivational Interviewing in your nursing practice will share your stories with us.

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