Motivational Strategies
Finding the spark that motivates the learner to
learn is challenging to the educator. The question remains, how does an educator motivate a
seemingly unmotivated individual or help a motivated person to remain motivated? As noted
earlier, incentives viewed as appeals or inducements to motivation can be either intrinsically
or extrinsically generated. Incentives and motivation are both stimuli to action. Bandura
(1986), for example, associates motivation with
incentives. He notes, however, that intrinsic (internal) motivation, although highly appealing,
is elusive. Only rarely does motivation occur
without extrinsic (external) influence. Green
and Kreuter (1999) note that “strictly speaking
we can appeal to people’s motives, but we cannot motivate them” (p. 30). Extrinsic incentives
are used for motivational strategizing in the educational situation.
Cognitive evaluation theory (Ryan & Deci,
2000) posits that knowing how to foster motivation is essential because educators can- not
rely on intrinsic motivation to promote
learning. They note, however, that autonomy
and competence are intrinsic motivators that
can be enhanced by selected teaching strategies. One contemporary nursing educational
strategy suggested that a way to promote motivation is concept mapping, which enables
the learner to integrate previous learning with
newly acquired knowledge through diagrammatic “mapping.” As a motivational technique,
concept mapping facilitates the acquisition of
complex new knowledge through visual links
that acknowledge previous learning. Learner
interest is sustained by perceived compe- tence
and autonomy. Concept mapping, as a less
instructor-regulated
learning
activity,
promotes interest and value on behalf of the
learner. A review of the health professions’
literature indicates that students and faculty
find concept mapping to be a valuable learning exercise (Hunter Revell, 2012; Taylor &
Littleton-Kearney, 2011; Torre et al., 2007; Wilkes, Cooper, Lewin, & Batts, 1999).
Motivational strategies for the nurse as educator are extrinsically generated using specific
incentives. The critical question for the nurse as
educator to ask is, “Which specific behavior, under which circumstances, in which time frame,
may be desired by this learner?” Strategizing begins with a systematic assessment of learner motivation, like that outlined in Box 6-1. When a
variable is absent or reduced, incentive strategizing is likely to move the individual away from
the desired outcome. When considering strategies to improve learner motivation, Maslow’s
(1943) hierarchy of needs also can be taken into
consideration. An appeal can be made to the
innate need for the learner to succeed, known
as achievement motivation (Atkinson, 1964).
In an educational setting, clear communication, including clarification of directions and
expectations, is critical. Organization of material in a way that makes information meaningful to the learner, environmental manipulation,
positive verbal feedback, and provision of opportunities for success are motivational strategies proposed by Haggard (1989). Reducing or
eliminating barriers to achieve goals is an important aspect of maintaining motivation.
One model developed by Keller (1987),
known as the attention, relevance, confidence,
and satisfaction (ARCS) model, focuses on
creating and maintaining motivational strategies that can be used for designing instruction.
This model emphasizes strategies that the educator can apply to effect changes in the learner
by creating a motivating learning environment:
■
■
■
■
Attention introduces opposing positions,
case studies, and variable instructional
presentations.
Relevance capitalizes on the learners’ experiences, usefulness, needs, and personal
choices.
Confidence deals with learning requirements, level of difficulty, expectations, attributions, and sense of accomplishment.
Satisfaction pertains to timely use of a
new skill, use of rewards, praise, and selfevaluation.
In motivational strategizing, it would also
be beneficial to consider Damrosch’s (1991) proposal that client health beliefs, personal vulnerability, efficacy of proposed change, and ability
to effect the change are important in patient education efforts.
Beliefs are a major construct proposed by
Wright et al. (1996) as the heart of healing in
families. Facilitating beliefs can promote a desired change, whereas constraining beliefs can
restrict options. Challenging constraining beliefs and promoting facilitating beliefs are, therefore, offered as motivational strategies.
An understanding of the individual’s mental representations or beliefs also is foundational
to the commonsense model in the representational approach to patient education (Leventhal
& Diefenbach, 1991). Beliefs constitute an underacknowledged and understudied phenomenon that needs to be further developed in the
education literature in terms of motivational
strategizing.
Motivational interviewing (MI) is another motivational strategy the nurse educator can use with learners (Droppa & Lee,
2014). It is a client-centered, directive counseling method in which clients’ intrinsic motivation to change is enhanced by exploring
and resolving their ambivalence toward behavior change (Miller & Rollnick, 2013). The purpose of MI is strengthening the motivation of
an individual to change. MI is a useful collaborative communication technique that facilitates engagement of patients in changing health
behaviors (Howard & Williams, 2016). Collaborative conversations are arranged in MI in a
way that facilitates an individual talking oneself into changing (Miller & Rollnick, 2013).
Dart (2011) states that “motivational interviewing fits perfectly into the nursing profession”
(p. 23) and represents a caring, respectful tool
with which to promote behavior change. MI is
a rapidly diffusing, empirically supported
approach to health behavior change (Antiss,
2009). Both as an assessment strategy and
as an intervention, MI supports client selfesteem and self-efficacy though emphasis on
the client’s own reasons and values for change
(Miller, 2004).
According to Miller (2010), the theoretical underpinnings of MI include Festinger’s
(1957) cognitive dissonance theory, Bem’s (1967)
self-perception theory, and Bandura’s (1977b)
self-efficacy theory. Carl Rogers’s (1951) work on
nondirective counseling and the FRAMES set of
data about the effective components of brief interventions for change (Bien, Miller, & Tonigan,
1993) also provide foundational relevancy for this
counseling method (Miller, 2010), as does selfdetermination theory (Markland, Ryan, Tobin,
& Rollnick, 2005). The MI approach integrates
well with two health behavior models discussed
later in this chapter: the transtheoretical model
of change (Prochaska & DiClemente, 1982) and
the therapeutic alliance model (Barofsky, 1978).
MI was initially used in substance abuse
treatment with adults, where it was developed
as a reaction to the confrontational methods
used in that field in the 1970s and 1980s. In this
counseling approach, the nurse as educator
avoids telling a patient what he or she needs to
do. Rather, the interview is a collaborative venture between nurse and patient whereby a positive atmosphere is created through a partner-like
relationship. The nurse guides rather than directs the patient. This approach stands in contrast to the classic relationship of expert provider
and passive recipient (Miller, 2004) that is often
seen in the traditional medical model. With MI,
the learner has more autonomy and the nurse
is less of an authority figure. Nurses can ask
patients useful questions that guide the direction of this counseling approach, such as what
changes are most important to them, how confident they are in being able to make changes,
what do they see as the benefits or drawbacks
in making changes in their lives, and how might
their lives be different if they carried through
with one or more of changes (Rollnick, Butler,
Kinnersley, Gregory, & Marsh, 2010)?
According to Miller and Rollnick (2013), the
spirit of MI includes collaboration (as opposed
to confrontation), evocation (as opposed to education), and autonomy (as opposed to authority).
Because change is ultimately the patient’s responsibility, this approach encourages motivation for change to come from within rather than
being imposed from the outside. Overall, MI is
a form of patient empowerment, with the goal
of helping patients gain control over the most
important lifestyle management decisions affecting their well-being (Soderlund, Nilsen, &
Kristensson, 2008). It consists of two phases: in the
first phase, the nurse helps the patient enhance
intrinsic motivation for change; in the second
phase, commitment to change is strengthened
(Miller, 2010; Miller & Rollick, 2013).
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 throughout the interview:
1.
2.
3.
4.
5.
Roll with resistance
Express empathy
Avoid argumentation
Develop discrepancy
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.
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.
2.
3.
4.
Open-ended questioning
Affirmations of the positives
Reflective listening
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.
BOX 6-2 provides examples of OARS questions and statements that the nurse educator
might use in an MI session.
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
BOX 6-2 Examples of OARS Questions and Statements
Open-Ended Questions
Could you share with me what has worked for you in the past when faced with a similar situation?
What are your current plans to accomplish your goal?
What do you believe you can accomplish at this time?
How do you believe it will feel to accomplish your goal?
Affirmation
You have worked very hard to get to this point.
You should be commended for all your positive efforts in meeting your goals.
It is obvious you have invested a lot into making these changes.
You have faced many challenges along the way, but you did not give up and now you are reaping the
rewards.
Reflection
Previously you said you wanted to . . . but truly you are afraid of making the changes to reach that goal.
On the one hand, you are happy with your current lifestyle, but on the other hand, you realize that
some changes need to be made.
You have worked on . . . in the past and have been unsuccessful and now you are afraid to try again
because you could fail.
Making a change is never easy, and you realize that you will have to put forth quite a bit of effort to
accomplish your goals.
Summary
Throughout our conversation, you have said you would like to . . . and will accomplish this by . . . in this
amount of time.
I would like to review what we talked about today.
To summarize what you just said . . .
We covered a lot today, and I would like to review what we discussed.
(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 educa- tion (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 re- lated 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 iden- tity 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 metaanalysis 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, Sandbaek, 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’Hallo- ran et
al. (2014) revealed MI with people who have chronic illnesses was a useful strategy in increasing their physical
activity levels. VanBu- skirk 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 addic- tive behaviors (except for smoking
cessation). Lundahl et al. (2010) performed a meta- analysis of 25 years of MI interviewing stud- ies, and their
analyses strongly suggested that “MI exerts small, though significant, positive
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 treat- ments,
the MI interventions took at least 100 fewer minutes of treatment on average yet pro- duced equal effects
(Lundahl et al., 2010). Also, another major study found as few as one MI ses- sion may be effective in enhancing
readiness to change behaviors to reach health goals (VanBu- skirk & 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 approx- imately 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 like- lihood 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 neg- ative 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.