Motivational Interviewing: Promoting
Adherence to Strengthen Transitions
Kathleen K. Zarling, MS, RN, CNS
Cardiovascular Clinical Nurse Specialist for
High-risk CAD patients
Mayo Clinic
Presented to the Minnesota Chapter, NACNS
October 26, 2012
Plymouth, MN
I Have No Disclosures
Kathleen K. Zarling, MS, RN,
ACNS
Objectives
Upon completion of this presentation, the
participant will be able to:
1. Define Motivational Interviewing
2. Describe the Four Main Principles of Motivational
Interviewing
3. Discuss the Essential Elements of Motivational
Interviewing: What it IS and what it IS NOT
4. Utilize individual Motivational Interviewing Techniques
in role play exercises
5. Identify Barriers to Motivational Interviewing
Motivational Interviewing
“Motivational Interviewing (MI) is a directive, clientcentered counseling style for eliciting behavior
change by helping clients to explore and resolve
ambivalence.”
(Rollnick & Miller, 1995, p. 325)
MI is a person-centered counseling method for
addressing the common problem of ambivalence
about behavior change.
(Miller, 2010)
Essential Elements of Motivational
Interviewing (MI):
Relational aspect
 Ambivalence is resolved through empathy
and a spirit that instills capability
Technical aspect
 Ambivalence is resolved through the selective
reinforcement of a client’s thoughts and
commitment for change
Ambivalence is Normal in Making
Lifestyle Change
♥
Ambivalence refers to
feeling two ways about
a behavior
♥
Getting stuck in
ambivalence is
common and should be
expected
I know I should exercise more,
But I just don’t have the time
Motivational Interviewing:
Technical Definition
MI is a collaborative goal-oriented method of
communication with particular attention to the
language of change. It is intended to strengthen
personal motivation for and commitment to a
target behavior change by eliciting and exploring
an individual’s own arguments for change.
(Miller, 2010)
Principles of Motivational
Interviewing
♥ To express empathy
♥ Support self-efficacy
♥ Develop discrepancy
♥ Roll with resistance
These four main principles must be maintained to have a
therapeutic interaction with patients.
(Levensky, Forcehimes, O’Donohue, & Beitz, 2007; Rolfe, 2004;
Miller, Zweben, DiClemente, & Rychtarik, 1992)
New Guiding Principles of
Motivational Interviewing
 R= To resist the righting reflex
 U= To understand & explore the patient’s own
motivations
 L= To listen with empathy
 E= To empower the patient
(Rollnick, Miller, Butler, 2008)
What Motivational Interviewing (MI) IS
NOT:
MI is not:
♥ Stages of change
 Decisional balance
 A Technique
 Just patient centered or client centered
counseling
 Not a form of Cognitive Behavioral Therapy
(CBT)
Essential Elements of Motivational
Interviewing (MI):
Can it be MI without
Engaging?
NO
The communication style and spirit
involve empathic, person-centered
listening
Essential Elements of Motivational
Interviewing (MI):
Can it be MI without
Guiding?
NO
There is a particular identified target of
change that is the topic of conversation
Essential Elements of Motivational
Interviewing (MI):
Can it be MI without
Evoking?
NO
The interviewer is evoking the person’s own
motivation for change
Selective eliciting, selective responding
Essential Elements of Motivational
Interviewing (MI):
Can it be MI without
Engaging
No
Guiding
No
Evoking
No
Planning
Yes
 Establishing a change plan
 Consolidating a commitment
The Spirit of Motivational
Interviewing
“The Dance”
♥ COLLABORATION~~NOT CONFRONTATION
♥ EVOCATION~~NOT JUST EDUCATION/ADVICE
♥ AUTONOMY~~NOT AUTHORITY
Carefully eliciting the values, assumptions, fears,
expectations, and hopes of the person.
Enhancing Patient Connectedness
Through the Nurse-Patient Relationship
♥ “Utilizing the theoretical framework of the theory of modeling and
role-modeling (MRM), patient connectedness is a relationship that
begins at the moment of initial contact between nurse and client
with recognition that the relationship itself is integral to the nurse’s
ability to model the client’s world.” (Erickson et al., 2006)
♥ “The initial relationship continues to grow and develop into a bond
between the nurse and the patient. The patient is the central focus
of the nurse’s care & all interactions and interventions are based
from the patient’s perspective.” (Mitchell, 2007)
Enhancing Patient Connectedness Through
the Nurse-Patient Relationship
♥ One of the greatest benefits of nurse-patient
connectedness is the establishment of trust between the
nurse and the patient
(Erickson, 2006)
♥ Patients tend to better trust nurses who establish a
relationship with them. (McCabe, 2004)
♥ An established relationship between the nurse and patient
will, many times, lead to a feeling of safety allowing the
patient to share more freely and openly with his/her nurse,
than with loved ones. ( Anderson, 2007)
Assisting Patients to Achieve Healthy
Behavior Change
#1. Accept that changing is difficult & each individual
must develop their own, individual way of
changing
(What works for one individual, does not always
work for another.)
#2. Understand that changing is a process, not a
single decision or act
(Change made over time can become a healthy
habit individuals don’t want to lose.)
#3. Make changes in small increments, as little
adjustments add up to big benefits
(Don’t try to change everything at once!)
Achieving Healthy Behavior Change
#4. Learn about & understand the stages of change
Stage I:
“I don’t need to change!” (Pre-contemplation)
Stage II: “Sure, I’ll change, but not right now. (Contemplation)
Stage III: “I want to change, but I’m not sure how to
start” (Preparation)
Stage IV: “Let’s do it!” (Action)
Stage V: “Now, if I can just keep at it!” (Maintenance)
Prochaska’s & DiClemente’s
Stages of Change
Prochaska, J.O., & DiClemente, C.C. (1982). Transtheoretical therapy: Toward a
more integrative model of change. Psychotherapy: Theory, Research, & Practice,
19, 276-288.
Motivational Interviewing Traffic
Light
Stop
Resistance
Elicit/Explore
Ambivalence
Move Forward
Change Talk
(Dart, Michelle A. (2011). Motivational
Interviewing in nursing practice:
Empowering the patient.)
Methods Used in Motivational
Interviewing:
♥ OARS
♥ DARN-CATS!
♥ CHANGE TALK
OARS –
“OARS”
♥ Open ended questions
♥ Affirmations
♥ Reflective listening
♥ Summary statements
“DARN-CATS!”….Elicits Change Talk
DARN:
♥ Desire
“What do you want, like, wish, hope, etc.?”
♥ Ability
“What is possible? What can or could you do?
What are you able to do?”
♥ Reasons
“Why would you make this change? What would
be some specific benefits? What risks
would you like to decrease?”
♥ Need
“How important is this change? How much do
you need to do it?”
“DARN-CATS!”….Elicits Change Talk
CATS:
♥ Commitment
♥ Activation
♥Taking Steps
CHANGE TALK
Involves The Client’s:
♥ Desire to Change
♥ Ability to Change
♥ Reason to Change
♥ Need to Change
The Coaching Conversation
Skills involved in the Mayo Clinic’s Wellness
Coaching Model:
♥ Engaging the patient
♥ Exploring values, strengths, & desires
♥ Facilitating a vision with a client
♥ Assessment & enhancing motivation
♥ Responding to resistance
♥ Recognizing & responding to change talk
♥ Utilizing E-P-E (Elicit-Provide-Elicit) when
providing information/advice
♥ Using empathic redirection communication
strategies
BRIEF INTERVENTION
E-P-E
Elicit- Provide- Elicit
 Elicit what they know
 Provide information
 Elicit what they think or feel about it
Barriers to
Effective
Motivational
Interviewing
Barriers to Effective Motivational
Interviewing
Collaborative Goal-Setting Challenges and Opportunities
♥ MI rests on a cooperative & collaborative
partnership between the patient &
clinician
♥ MI addresses a specific situation where
patient change is needed
♥ MI utilizes an active & equal collaboration,
conversation & joint decision-making
between the client and patient
(Rollnick, Miller, and Butler, 2008)
Role Play on Developing Ambivalence
& Discrepancy to Promote Behavior
Change
♥ Work in a group of three
♥ Each individual take 5 minutes to role-play
with one other individual, with the third
individual being the observer, sharing
observations
♥ Please make sure each of you has time to be
the interviewer
Promoting
Adherencecan
& be
Strengthening
Cardiac Rehabilitation
productive for
EVERYONE!
Transitions Creates
Quality Care
THANK YOU!
zarling.kathleen@mayo.edu