The Stages of Change Model:
Making changes to established habits can be challenging and simply giving patients advice about the lifestyle choices needed to achieve a healthier life can often be met with resistance, inaction and residual ill health.
Without additional assistance lifestyle prescriptions are often ignored, so how can healthcare professionals help their patients to overcome resistance to change?
One answer comes from the developing field of motivational interviewing (MI).
What is Motivational Interviewing?
Motivational interviewing is a well established patient-centred approach that supports behaviour changes (Britt 2004).
When first developed by Miller and Rollnick over two decades ago, MI was used mainly in the fields of addiction and substance misuse (Rollnick 2010). Today, however, it’s use has broadened to embrace a diverse range of clinical settings and patient groups.
Although primarily used in the field of health promotion, MI is now also having a significant impact on patients’ self-management of some of the most serious diseases caused by lifestyle factors.
As Rollnick et al. (2010) suggest, by incorporating some basic conversational changes into consultations it’s possible to assist behaviour change by guiding patients to clarify their strengths and aspirations, evoke their own motivations for change, and promote autonomy of decision making.
How Does Motivational Interviewing Work?
Simply giving patients advice to change is often unrewarding and ineffective.
Motivational interviewing, on the other hand, takes the basic communication skills of reflection, active listening and open-ended questioning and uses these skills to guide rather than lead the patient towards healthier outcomes.
Central to the success of MI is the ability to help patients clarify their strengths and aspirations, raise their desire and motivation to experience better health and strengthen their decision-making process. It’s a consultation style that places the locus of control with the patient, assisting them to tap into their own inherent resources.
Guiding Principles of Motivational Interviewing
- How we speak to people is likely to be just as important as what we say
- Being listened to and understood is an important part of the change process
- The person who has the problem is the person who has the answer to solving it
- People only change their behaviour when they feel ready, not when they are told to do so
- The solutions people find for themselves are the most enduring and effective.
To be successful, practitioners must be able to identify the patient’s core values and goals and use this as a basis to encourage behaviour change.
Use of positive solution-focused language throughout the conversation is also key to gaining agreement to health-enhancing changes. This is reflected in the four basic principles of MI.
Four Basic Principles of Motivational Interviewing:
- R – resist the urge to change the individual’s course of action through didactic means
- U – understand it’s the individual’s reasons for change, not those of the practitioner, that will elicit a change in behaviour
- L – listening is important; the solutions lie within the individual, not the practitioner
- E – empower the individual to understand that they have the ability to change their behaviour
Moving From “I Might” to “I Will”
Many healthcare professionals still trend towards a paternalistic style of conversation by ‘telling’ patients what they need to do.
In many cases, there is nothing wrong with this. It’s how we inform, prescribe and teach, and for most patients most of the time that is a helpful approach to take. It assumes that the patient is willing and able to change.
However, when lifestyle changes are needed, that approach doesn’t always work.
If a patient isn’t sufficiently willing, able, focused or motivated to ‘change’ without additional help then using techniques such as motivational interviewing can be a useful way of helping them to move past their own resistance and take action.
Simply shifting from direct suggestions and ‘telling’, to using indirect suggestions and asking, can help raise motivation and the desire for something better. It’s a relatively easy way of helping someone who may be resistant to change to focus on their best potential and increase their willingness to take action.
Using Solution-Focused Questions to Encourage Change
There are many similarities between motivational interviewing and solution-focused therapy as Stermensky et al. (2014) point out.
For example, embedding solution focused presuppositions into conversations about lifestyle changes is just one way nurses can help focus the patient’s attention on achieving a positive result.
A presupposition is simply an assumption which can be used conversationally to help guide someone to fulfil an outcome.
Linguistically the presupposition must be assumed to be true for the sentence to make sense and so it becomes a fast and effective way of bypassing conscious resistance to an idea.
Nurses are ideally placed to embed solution focused questions into conversations. It’s an easy, cost free, intervention that has the potential to help patients recognise and overcome any obstacles in the way of change. (RCN 2018)
- When would you like to start?
- How would you like to move forward?
- How do you imagine us working together?
- How do you see me being the greatest help to you?
- How will you know if this choice/ treatment/ has been a success, what will have changed for you?
Is Motivational Interviewing Supported by Current Research?
Motivational interviewing has been shown to promote behaviour change in a wide range of healthcare settings (Rollnick 2010).
To date research results have proved extremely promising as a precursor, or complement to other interventions. A wide selection of high-quality research and training resources can also be accessed online (MINT 2017).
Are Motivational Interviewing Skills a Realistic Option in Practice?
Although initial support for MI came from practitioners working in the field of addictions, it’s now recognised as an intervention that can be adapted and applied to a range of problem behaviours, having a ‘common currency’ among health professionals (Ashton 2011).
Bunyan et al. (2017) suggest that learning the skills of motivational interviewing might be a useful way of helping nurses to improve their communication skills and think in detail about their interactions with patients.
This stands in some contrast to the views of Noordman et al. (2012) who suggests that motivational interviewing skills are not easily applicable in routine practice.
Yet, it could be argued that a middle way also exists by taking techniques from the motivational interviewing approach and integrating these into routine patient consultations (RCN 2018).
As Scott (2010) points out, nurses could play a major role in improving health outcomes simply by incorporating motivational interviewing skills into therapeutic conversations, potentially addressing some of the productivity challenges of modern healthcare systems.
- Ashton, M 2011, ‘Improving training in motivational interviewing’, in Nursing Times, 11 November, viewed 6 March 2018, https://www.nursingtimes.net/roles/nurse-educators/improving-training-in-motivational-interviewing/5037735.article
- Britt, E, Hudson, SM & Blampied, NM 2004, ‘Motivational interviewing in health settings: a review’, Patient Education and Counseling, vol. 53, no. 2, pp. 147-55, viewed 6 March 2018, https://www.ncbi.nlm.nih.gov/pubmed/15140454
- Bunyan, M, Crowley, J, Smedley, N, Mutti, MF, Cashen, A, Thompson, T & Foster, J 2017, ‘Feasibility of training nurses in motivational interviewing to improve patient experience in mental health inpatient rehabilitation: a pilot study’, Journal of Psychiatric and Mental Health Nursing, vol. 24, no. 4, pp. 221-31, viewed 6 March 2018, http://onlinelibrary.wiley.com/doi/10.1111/jpm.12382/full
- Excellence in Motivational Interviewing 2017, Motivational Interviewing Resources, MINT, viewed 6 March 2018, http://www.motivationalinterviewing.org/motivational-interviewing-resources
- Noordman, J, van Lee, I, Nielsen, M, Vlek, H, van Weijden, T & van Dulmen, S 2012, ‘Do Trained Practice Nurses Apply Motivational Interviewing Techniques in Primary Care Consultations?’, Journal of Clinical Medicine Research, vol. 4, no. 6, pp. 393-401, viewed 6 March 2018, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3513421/
- Royal College of Nursing 2018a, How motivational interviewing works, RCN, viewed 6 March 2018, https://www.rcn.org.uk/clinical-topics/supporting-behaviour-change/motivational-interviewing
- Royal College of Nursing 2018b, Asking effective questions, RCN, viewed 6 March 2018, https://www.rcn.org.uk/clinical-topics/supporting-behaviour-change/asking-effective-questions
- Rollnick, S, Butler, CC, Kinnersley, P, Gregory, J & Mash, B 2010, ‘Motivational interviewing’, BMJ, viewed 6 March 2018, http://www.bmj.com/content/340/bmj.c1900.full
- Scott, G 2010, ‘Motivational interviewing 1: background, principles and application in healthcare’, in Nursing Times, 28 August, viewed 6 March 2018, https://www.nursingtimes.net/clinical-archive/motivational-interviewing-1-background-principles-and-application-in-healthcare/5018759.article
- Stermensky, G & Brown, KS 2014, ‘The Perfect Marriage: Solution-Focused Therapy and Motivational Interviewing in Medical Family Therapy’, Journal of family Medicine and Primary Care, vol. 3, no. 4, pp. 383-7, viewed 6 March 2018, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4311347/