Facilitating Change: Motivational Interviewing and Appreciative Inquiry



Facilitating Change: Motivational Interviewing and Appreciative Inquiry


Mary Elaine Southard

Linda Bark

Darlene R. Hess



Nurse Healer OBJECTIVES









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Theoretical



  • Describe each of the four guiding principles of motivational interviewing (MI).


  • Identify eight foundational assumptions of appreciative inquiry (AI).


  • Describe the 4-D cycle of appreciative inquiry.


Clinical



  • Describe the use of appreciative inquiry in a patient-centered exchange.


  • Describe the use of motivational interviewing in a patient-centered exchange.


Personal



  • Discuss how empathy is an essential component of a helping/caring relationship.


  • Explore the importance of a healing presence.


  • Describe how active listening enhances nurse-patient interactions.




DEFINITIONS

Appreciative inquiry: Appreciative inquiry (AI) is both a philosophy and a methodology for change. Appreciative inquiry is the study and exploration of strengths as a way to help patients and organizations function at their best. Instead of solving problems, AI is a process in which positive change is facilitated through identifying creative possibilities.

Empathy: An ability to “sense the patient’s private world”; an essential component in understanding another person. Human sensitivity is developed by perceiving others and experiencing an awareness of the situation of the other.

Motivational interviewing: Motivational interviewing (MI) is an intervention strategy for changing behavior. The central purpose of MI is to help patients explore and eventually resolve ambivalence in reference to a current health behavior. MI emphasizes client choice and responsibility and can be used in a variety of clinical settings.

Nurse coaching: Holistic nurse coaching is skilled, purposeful, results-oriented, and structured relationship-centered interactions with clients provided by registered nurses for the purpose of promoting the health and well-being of the whole person. Nurse coaching is grounded in the principles and core values of holistic nursing. Effective nurse coaching interactions involve the ability to create a coaching partnership, build a safe space, and be sensitive to client issues of trust and vulnerability as a basic foundation for further exploration.1 Nurse coaches are able to structure a coaching session, explore client readiness for coaching, facilitate achievement of the
client’s desired goals, and cocreate a means of determining and evaluating desired outcomes and goals.2

Therapeutic presence: Therapeutic presence is the conscious intention to be fully present for another person as a way to promote health, healing, wholeness, and well-being. Presence is generally defined as a multidimensional state of being available in a situation or exchange with another, acknowledging the sacred quality and interconnectedness of each person. Presence involves letting go of past or future concerns, resulting in the creation of an opening or opportunity to reveal what is needed in the moment.3 Presence requires awareness, authenticity, and an appreciation of being in the moment.

Transtheoretical Stages of Change Model (Transtheoretical Model): The Transtheoretical Stages of Change Model is a model of behavioral change developed by Prochaska and DiClemente in 1984.4 The five stages of the model are precontemplation, contemplation, preparation, action, and maintenance. Interventions designed to promote behavioral change are tailored to the individual’s readiness for change. Relapses and recycling through the stages frequently occur. Relapse provides valuable information to assist in further change and is not viewed as a failure.


▪ INTRODUCTION

This chapter concerns two holistic interventions nurses can learn and use in professional nursing practice to support client behavior change to enhance client health and well-being. Nurses have always been involved in health promotion and disease prevention. As healthcare systems developed over the past 50 years, nurses have witnessed the redirection of funding from health promotion efforts, primarily delivered through public health departments, to disease care delivered increasingly by private institutions and funded by complex payment mechanisms. Nurses have advocated for increased attention to the role that nurses play in assisting clients to adopt healthier lifestyles and change unhealthy health behaviors. Now policy makers, health professionals, and the general public are awakening to the fact that unless significant changes are made, our nation will become increasingly burdened by runaway healthcare costs for treatment of conditions that could be eliminated or significantly ameliorated by behavioral changes. A report by the Kaiser Family Foundation (2010) indicates that workers are paying a notably larger share of health insurance expenses.5 The cost of the average annual premium for a family policy increased 114% in the past decade and worker contributions accelerated 147%. More than a quarter of insured workers—up from 10% in 2006—now have a deductible of at least $1,000 for single coverage alone. Experts forecast that out-of-pocket expenses will continue to go up.

As a result of these huge healthcare cost increases, employers and insurance companies are looking for ways to lessen disease progression and promote policies and create systems that lead to improved health. Health professionals are looking for effective and cost-efficient ways to help clients make health behavior changes. Hospitals are exploring and developing coordinated systems to decrease hospitalizations, to reduce use of medications and other costly treatments, and to enhance the effectiveness of the care provided by health professionals. Health promotion and disease management programs now offer incentives to promote self-management. Unfortunately, many of these programs do not produce the desired results.

New approaches are needed to assist patients to achieve lasting behavior change. “Health professionals cannot assume that the only path to improving healthy lifestyles is looking for clients’ problems in compliance and solving them.”6pS72 Ever-increasing numbers of nurses are learning evidence-based ways to assist clients to make the behavioral changes that can lead to improved health and well-being. Holistic nurse coaches are taking the lead in establishing models of coaching that are designed to engage clients in selfcare and management of healthcare practices and outcomes.2 Although there are many holistic strategies and approaches for assisting patients to reach their full potential, two accepted approaches used by many nurses are motivational interviewing and appreciative inquiry. Motivational interviewing is used when someone is ambivalent about change. Appreciative inquiry
uncovers and expands what is working in a situation rather than focusing on what is not working.


▪ MOTIVATIONAL INTERVIEWING

Motivational interviewing (MI) is a wellknown, research-based method of interacting with patients that was developed in the 1980s to improve outcomes associated with substance abuse.7 MI is a skillful interaction for eliciting motivation for change. The fundamental premise of MI is that patients are often ambivalent to change, and ambivalence affects a patient’s motivation and readiness to alter behavior.8

The Transtheoretical Model created by DiClemente and Prochaska guides MI.7 DiClemente and Prochaska noticed that people frequently do not succeed in changing behavior on the first attempt and often experience numerous attempts before successfully changing. There are multiple stages, progression, and relapses. Underlying the progressions are the patients’ prior experiences with change and how they view the pros and cons of change. Patients consider whether or not they have the skills or resources to make a change.

MI is used in all aspects of behavior change. Motivational interviewing has been identified as an effective tool to improve medication adherence.9 Adult patients with asthma who participated in a single session of education plus motivational interviewing were more likely to show an increased level of readiness to adhere to medication regimens compared with patients receiving education alone.10 Patients with schizophrenia who participated in eight motivational interviewing sessions experienced significant improvement in overall psychotic symptoms and attitudes toward and satisfaction with medication compared with usual treatment.11

The application of motivational interviewing in addition to a comprehensive behavioral weight loss program has been shown to aid weight loss by increasing motivation. When MI was incorporated into a behavioral weight loss program, participants lost significantly more weight and engaged in significantly greater physical activity than did those in the program who did not receive motivational interviewing.12

Numerous studies have been published indicating that the use of MI is an effective intervention to reduce smoking.13 MI has been shown to be more effective with a variety of medical problems than traditional clinical advice giving. MI can help people reduce alcohol consumption, lose weight, and lower blood pressure.14


Guiding Principles of Motivational Interviewing

Motivational interviewing is based on four guiding principles known by the acronym RULE:15



  • Resist the righting reflex. The “righting reflex” is the natural tendency of the nurse to fix a patient’s problems by imposing solutions.16 The nurse must set aside any desire to correct the course and direction of the client. If the nurse is pushing for change and the client is resisting, the nurse is in the wrong role; it is the client who should be voicing the arguments for change. The nurse must suppress what may seem like the right thing to do and instead allow the client to determine what to do.


  • Understand and explore the client’s motivation. It is the client’s reasons for change, and not the nurse’s, that are likely to trigger change. The nurse explores the client’s concerns, perceptions, and motivations. Allowing patients to tell their story and encouraging them to discuss not only their reason for change but also how they might see themselves make those changes is the core of the partnership.


  • Listen with empathy. Answers lie within the client, and finding them requires listening. Good listening is a complex skill; it is more than asking questions and keeping quiet long enough to hear the reply. Empathy has been defined as a complex, multidimensional phenomenon16 but is typically understood as the ability to identify with the client’s difficulties or feelings. The ability to express empathy enhances the ability to engage patients in making necessary health changes and is a key component of MI.


  • Empower and encourage hope and optimism. The nurse helps the client discover how change can happen. The nurse views the client as the expert consultant as ideas and resources for change are explored. Providing ongoing encouragement to foster the belief that the goals are achievable can help the patient carry out a plan to change behavior.



Partnering with Clients

By honoring client autonomy and effectively creating a collaborative partnership between patient and provider, nurses enable patients to become involved in identifying goals and determining how best to achieve them. Individuals are naturally motivated to improve their own well-being, and their willingness to become involved in managing their own care is closely tied to their ability to set goals and to their hopes for the future.17 Accessing a client’s hope for improved outcomes is a vital component of effective coaching for change.18 The nurse applying an MI strategy seeks to evoke client strengths and to activate client motivation and resources for change.

MI is a refined form of guiding and includes skillful informing. The process of listening and guiding patients is a quite different stance from telling patients what they “should” be doing in terms of positive healthcare practices. For example, telling a patient she needs to cut down on calories or providing her with a dietary referral may be a misstep or lost opportunity to engage in meaningful dialogue that uncovers information that can enhance outcomes.

In motivational interviewing, the goal of the nurse coach is not to point out discrepancies between goals and behavior but to incrementally guide the patient to self-discovery. Selfefficacy is supported when the patient realizes that behavior and goals are not congruent and makes a conscious decision to make necessary changes. Nurses who utilize MI understand that it is not the nurse’s job to fix the patient or the patient’s problems. To attempt to do so places responsibility on the nurse and promotes either dependency on the nurse or leads to “difficult” patients who do not listen to the information or advice provided by the nurse.19 Nurses using MI learn to go down the patient’s path rather than create the path and expect the patient to follow.


Communication Skills

To negotiate behavior change successfully, nurses must build on basic communication skills and establish a therapeutic environment. Holistic nurses understand that sacred presence is invaluable in setting the stage for exploring the change process. Coaching clients to achieve their desired goals involves developing and honing specific communication techniques such as reflective listening, asking open-ended questions, and using clarifying statements. Using active/reflective listening ensures that the nurse understands the patient and his or her readiness to initiate change. Open-ended questions foster dialogue and the ability to gauge deficits/strengths in relation to desired changes. Inquiring about what the patient already knows and asking if the person would like additional information show respect.

Self-awareness is a necessary component of effective partnering with clients to effect change. Communication is facilitated when the nurse is aware of his or her voice inflections, posturing, or self-talk when interacting with a patient.

Practitioner time constraints and the perception by the client of a hurried approach can be a challenge and a barrier to empathic active listening. This can lead to unintended results and patient dissatisfaction. Increased use of technology has created streamlined documentation and time-saving record keeping processes while unfortunately often creating barriers to being fully present. However, motivational interviewing can be a time-saver by identifying the patient’s goals, concerns, and ideas before proceeding with potentially ineffective interventions.


Application of Motivational Interviewing in the Clinical Setting

MI can be used in a variety of clinical settings. The following case study illustrates how MI can be used to assist a patient to stop smoking.




MOTIVATIONAL INTERVIEWING CASE STUDY

Setting: Clinic

Patient: J. V., a 64-year-old woman with a history of severe chronic obstructive pulmonary disease (COPD)

Patterns/challenges/needs: Wants to stop smoking

J. V. has been diagnosed with severe COPD, has had several hospitalizations over the last 4 years, and continues to smoke heavily. Last year, she was in the precontemplation stage of smoking cessation with denial statements that ranged from “I don’t have a problem” to “I don’t have
any willpower and I could never stop smoking.” However, following her most recent hospitalization, she moved into the contemplation stage of change, realized she did have a problem and wanted to do something about it, but still she believed she couldn’t stop smoking.






































































































Patient and Nurse Conversation

Motivational Interviewing Guidelines


Nurse: Good afternoon, Mrs. V. It is good to see you again.


J. V.: Thanks. I like seeing you, too. It’s nice when I get to see the same person.


Nurse: It’s nice for me, too. It allows me to follow up with patients, and I know that last time after your hospitalization you described the pros and cons of quitting smoking.

Motivational interviewing is especially designed to deal with people who are ambivalent about making health changes.


J. V.: Oh, I hate even talking about that. I just have no idea how I would ever give up that habit. You know I have been smoking since I was 16.


Nurse: I can understand why you feel that way, but last time you did have some interest in thinking about reducing your smoking.

Validate the patient’s feelings and experiences.


J. V.: Yes, you’re right. Being in the hospital was really awful, and the doctor showed me some pictures of my lungs and how my smoking makes them worse.


Nurse: So, you actually saw with your own eyes how smoking hurts your lungs?

Reinforce reasons for change and repeat in simple, direct statements about the effects of patient’s choices.


J. V.: Yes, it was quite obvious.


Nurse: How has your decreased lung capacity affected your life?

Explore potential concerns.


J. V.: Well, it does really limit my activity. I have a grandchild who is now 2 years old and I can’t keep up with him at all. I can see that my capacity to be with him is getting worse. And, of course, just shopping and other activities are limited. My family is after me all the time to quit smoking. Even my older grandchildren are starting on me.


Nurse: It is hard to change something in your life when others are pressuring you. It’s up to you to make this decision about when and if you want to make a change in this behavior. Thanks for even talking to me about this. I know it is hard for you.

Acknowledge the patient’s control of the decision.


J. V.: Yes, it is, and it’s nice that you know that.


Nurse: I remember that we talked about your interest in smoking before, and using a 1 to 10 scale, you said you were at a 5. What is the number today?

Explore interest in change.


J. V.: Hum. Let me see. I guess it has moved up to a 6.


Nurse: What does that number mean to you and how would you define it in words?

Explore meaning about change.


J. V.: Well, I guess it means that I want to stop smoking more than I don’t want to. Maybe I have fallen off the fence this time, but you know I can always get back on the fence.


Nurse: Of course, using your control to change is always your decision.

Reinforce the fact that the patient has control.


J. V.: Yes, you’re right.


Nurse: Tell me why you chose a 6 today?

Explore how things have changed.


J. V.: I just keep thinking about how my breathing limits my life and it makes me want to stop.


Nurse: I understand how your life would be different if you changed your smoking habit.

Reinforce concerns and the benefits of changing behaviors.


J. V.: I think about stopping, but then I get really scared and think I can’t do it.


Nurse: So, you have an interest, desire, reasons, and a need to change, but you are worried about your ability? If we were to rate your ability to change on that 1 to 10 scale, what would your number be?

Assess interest, desire, reasons, needs, ability, and commitment as appropriate.


J. V.: Now that is the real question. I think it is a zero. If it were higher, all those other numbers would go up too.


Nurse: So, your belief that you can do it is really what is holding you back now. What would move you from zero to one?

Explore what would need to change for movement toward behavior change.


J. V.: Well when you ask that question, it doesn’t seem too hard, but I still don’t know. I really don’t know what would work for me to go from zero to one.


Nurse: Almost every person who quits smoking starts being concerned about their ability to change their smoking habit. If it is okay, I would like to tell you some things that have helped other people.

Reframe concern about inability to change.


J. V.: Okay.


Nurse: One of the patients who talked with me this morning began by cutting out one cigarette a day. Yesterday, a man decided not to smoke in one room of his house. Last week, a woman decided she would not smoke from 10 AM to 11 AM just to see if she could get some control of her habit.

Offer suggestions that are beginning steps for change.


J. V.: I can see how that might work for them, and something like that might work for me. Now I am almost at a 1.


Nurse: That is great to see change in your belief about your ability to quit smoking. I see that our time is moving to a close here. What kind of change, if any, do you want to make this next week?

Reinforce change.


J. V.: Well, I guess I could say that I won’t smoke between 10 AM and 11 AM. I don’t think I smoke much then anyway, so I think it will be easy. I kind of feel good about some kind of beginning.


Nurse: So, the initial goal is to limit smoking during that hour. On that old 1 to 10 scale, how committed are you to follow through on that goal?

Encourage small, initial steps. Assess commitment.


J. V.: I don’t exactly know. I suppose I am pretty high … maybe an 8 and don’t ask me how to get to a 9. I am happy with an 8.


Nurse: An 8 is great! I am very happy for you and really look forward to talking with you about this experiment at your next appointment. Congratulations on your progress today.

Encourage small, steady steps.


J. V.: Well, to tell you the truth, it feels good to me, too. I never thought I could take this first step. And even though I asked you not to ask me about what would get me to a 9, when you called my not smoking for an hour a day an experiment, that made it sound more doable and not so scary.

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Jun 21, 2016 | Posted by in NURSING | Comments Off on Facilitating Change: Motivational Interviewing and Appreciative Inquiry

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