Motivational interviewing was first described by Miller in 1983, for a study examining the treatment of alcoholism (now known as alcohol use disorder). The term has widely caught on throughout healthcare systems as a way to help the patient put into practice health promotion strategies such as nutritional recommendations for diet changes or healthier behaviours such as incorporating exercise into a daily routine, by ensuring the patient realises for themselves that they have the power to make changes, they recognise the problem, recognise how to deal with the problem, and feel motivated with a plan going forward to implement the necessary changes. Simply giving a patient advice is not enough – a strategy as to how the information is taken on and how the patient thinks, feels and behaves are integral to incorporating the necessary changes required for their health. A university lecturer, Stephen Rollnick (2010), has studied the technique and specialises in the training of others to understand how to implement it. Rollnick (2010) described that simply giving advice to patients to ‘change’ is not efficacious on its own.
Motivational interviewing helps to clarify the person's strengths and aspirations, inspires motivation to change and encourages independence in decision making, therefore empowering the person to feel they can take the challenge on to make change. Rollnick (2010) discusses that this style of patient engagement has been shown to promote behavioural change in various healthcare settings, and it improves relationships between clinicians and patients, while improving efficiency in achieving better health outcomes. The principles involve directing, guiding and following.
The Royal College of Nursing (RCN, 2019) summarises the five key skills for motivational interviewing. The first skill involves an open discussion that explores why the person is fearful of change or exploring, using open questions, why the person feels low or lacks motivation recently. Reflective listening ensures the person knows they are understood by the practitioner and reinforces the interest the patient feels the practitioner has in them and their health, by the practitioner being able to reflect a summary of the issues. Clarification shows the person that they are understood. When reflecting it is important to avoid making assumptions, judgments or enforcing your own beliefs – instead focus on expressing that you are ‘getting a sense’ of what they have told you, then clarify the plan for moving forward. Summarise the concerns, the negative consequences identified, the plan, then elicit motivational statements such as reminding them how well they have done previously and that they can do this again, empowering them through positively appraising the plan they have made.
Tackling the obesity crisis using motivational interviewing
Exercise is found by many researchers to have a positive effect on mood, self-esteem and other aspects of mental health, as well as a high impact on physical health and therefore the risk of long-term health conditions. It is important a patient understands why exercise can help them, but also that they are motivated to change. Exercise can tackle obesity but it can also tackle depression. Pearce et al (2022) observed that exercise is a powerful tool in fighting depression by promoting positive changes in the brain, including neural growth, reduced inflammation, and new activity patterns that promote feelings of calm and well-being, while also releasing endorphins (Pearce et al, 2022).
Wade et al (2018) studied use of the technique for encouraging weight loss, noting the significant burden obesity has on health services due to it being linked to increased risk of over 20 chronic conditions. Ensuring people are active is a public health challenge and therefore the team wanted to use a behavioural intervention that was already being used in primary care, to examine its effectiveness in encouraging a more active lifestyle for at-risk patients. The researchers looked at changes in physical activity and mental wellbeing as outcomes for examining the community-based intervention grounded in motivational interviewing.
The research took place in Essex and the project title was, ‘Let's Get Moving’. Eligible participants had to be between 18 and 74 years old with a body mass index of 28–35 kg/m2. Firstly, a motivational interviewing appointment was carried out for half an hour, at the beginning of the patient's involvement. The person was then signposted to relevant activities and the data was collated. The 12-week data were collated during a face-to-face appointment, then at 6 and 12 months follow-ups were carried out over the phone. In order to measure the outcomes, the team got the participants to self-report physical activity levels using the International Physical Activity Questionnaire (IPAQ), and mental wellbeing was measured using the Short Warwick Edinburgh Mental Wellbeing Scale (SWEMWBS). Of the 2084 participants, about 60% were female and two-thirds had a disability. The sample was predominantly White or White British and therefore may not be generalisable across all ethnicities and cultures. The study found that there were significant increases in vigorous and moderate intensity physical activity, walking and mental wellbeing (Wade et al, 2018). Therefore, the researchers concluded that physical activity intervention grounded in motivational interviewing appears to be highly effective, although bias could not be ruled out for the study (Wade et al, 2018).
‘The researchers concluded that physical activity intervention grounded in motivational interviewing appears to be highly effective.’
Motivational interviewing for newly discharged patients in the community
Brandberg et al (2021) studied the self-management challenges that exist following hospital discharge with patients with multiple conditions. The aim of their research was to describe the challenges faced over time during the four weeks following hospital discharge, as it is common for vulnerable patients to often be readmitted, and this would inevitably relate to challenges faced following leaving the hospital. Motivational interviewing was used for 16 participants, who either had heart failure or chronic obstructive pulmonary disease in combination with at least one other comorbidity. The participant then had four or five motivational interviewing sessions with a trained social worker over a period of 4 weeks, which were all digitally recorded and analysed using content analysis. The researchers noted that when people feel motivated, engaged and have a greater sense of psychological wellbeing, positive health behaviours are far more likely. They noted the importance of patient autonomy. This can be difficult when a patient is generally chronically unwell yet they face the prospect of leaving a full care environment full of practitioners to possibly living independently alone again, and this could be following months in hospital. Follow-up care would be given when required in the community but it is still a very different environment to adjust to, making the patient vulnerable and possibly overwhelmed, demotivated and anxious about their situation, leading to worse health behaviours, health outcomes and possible readmission.
The patients had their first motivational interview sessions 1–2 days following discharge to ensure first contact was established and to acknowledge any concerns or questions arising early. The patients then had sessions weekly thereafter, post-hospitalisation. These sessions helped to examine change over time post-discharge and to capture the difficulties that may lead someone back to readmission. However, due to motivational interviewing the practice enabled these difficulties to be acknowledged and managed in the community, while also observing issues that can be applied to practice for patient populations. By the fourth session, some patients stated they felt they could manage their situation and no longer required the intervention.
Brandberg et al (2021) noted the importance of motivational interviewing as it can help the patients to self-manage and therefore avoids deterioration or readmission. Brandberg et al (2021) felt the four key areas that motivational interviewing could address in order to avoid readmission and to encourage better health following discharge, were: managing medications; managing symptoms or signs or worsening illness post-discharge; acquiring knowledge of follow-up; and acquiring knowledge of and control over whom to contact for different healthcare needs. The sessions enabled the researchers to observe that self-management is a dynamic process affected by managing system-centred care along with the burden of living with multiple comorbidities. They noted that patients with multiple comorbidities need support during the first 2-weeks post-discharge and that system-centred healthcare does not necessarily suit someone with multiple chronic conditions, instead targeting a single-disease population, which in Western culture is difficult to apply given the amount of people living with multiple chronic illnesses. By adapting the process in the community following patient discharge, through empowerment and identification of changing needs using motivational interviewing, this may be a better way to encourage good health to stay on track and to avoid hospital readmission.
Brandberg et al (2021) discussed that self-management is a dynamic process that changes rapidly throughout the first weeks following hospital discharge. Patient needs shift and change during this time and if these are identified and addressed through motivational interviewing in this early post-discharge period, outcomes may be improved for both the patient and healthcare system.
There are multiple other areas that can be addressed using motivational interviewing. Addiction is an ever-increasing public health concern and also could benefit from the intervention, as found by Satre et al (2016) in their randomised controlled trial, which found cannabis use and hazardous alcohol use could be helped through the use of the intervention. Similarly, Ma et al (2014) found the intervention benefited patients with hypertension.
In fact, Ma et al (2014) found the systolic blood pressure and diastolic blood pressure of hypertensive patients significantly decreased in the participants who received motivational interviewing for 6 months. They concluded that the intervention should be used in hospitals and in primary care, and that training should be provided to nurses so they could practice this in their work with any patient.
Conclusion
In summary, the key is to ensure all staff know how to engage a patient using this method, as by motivating and empowering a patient to choose for themselves, and repeating this conversation regularly with the patient, not only can any concerns be addressed as they arise, but adherence to healthier behaviours can be increased.