Diane, a 72-year-old woman with a history of type 2 diabetes, is overweight and fatigued, and she struggles with joint pain. She currently provides daily childcare for her young grandson and has made off-hand comments to you, her primary care nurse practitioner (NP), about “not being able to keep this up forever.” You suspect she has fears about being able to maintain her health into the future. You know that physical activity is one of the primary modifiable risk factors for the prevention and improvement of many chronic diseases, but you also know that the majority of your patients do not get the amount of aerobic or muscle-strengthening activities recommended by the Centers for Disease Control and Prevention (CDC; 2011). For many of the older adult patients in your practice, a small increase in activity would constitute a significant improvement (CDC, 2011).
You decide to address this with Diane at her appointment today; assuming that once she knows the facts and follows your reasoning, surely she will commit to regular exercise. When Diane mentions her fatigue, you remind her of the burden of her extra weight and recommend a regular exercise program. You explain that, as an individual with diabetes and the responsibility of caring for her grandson, increasing her physical activity is especially important for her. You list the benefits of regular exercise (e.g., weight loss, increased energy, better diabetes management, decreased joint pain, improved cardiovascular health). You then suggest a few options for exercise (e.g., water aerobics, walking around the track, gentle yoga). To your surprise, Diane looks less than engaged. You emphasize why increasing her physical activity is so important for Diane, reminding her of the risks of continuing her sedentary lifestyle. As you walk her to the door, you feel pleased that you were able to address this important topic today. However, Diane reschedules her next appointment three times, and by the time you see her, she sheepishly admits to not having increased her physical activity at all. What went wrong? Why is she not listening?
Many individuals considering lifestyle changes become mired in ambivalence, a mental state defined as feeling stuck between the pros and cons of a decision and being unable to take action. Motivational interviewing (MI) is a counseling style that helps practitioners guide patients through ambivalence about a potentially beneficial behavior change by using specific conversational techniques. The practice can help an NP avoid methods of communication that tend to be ineffective for ambivalent patients. A departure from the traditional method of promoting change through education and reason, MI releases the practitioner from the burden of convincing the patient to alter his or her behavior and instead allows the patient voice his or her arguments for the change. The purpose of the current article is to introduce NPs to the use of the MI conversational style for encouraging physical activity in older adult patients.
Promoting Physical Activity Within Primary Care
The challenge of getting older adults to maintain regular physical activity has been well documented (Tak, Kuiper, Chorus, & Hopman-Rock, 2013). In the primary care setting (where many chronic diseases are managed), many obstacles exist to addressing a patient’s level of physical activity. A survey of NPs found that approximately one half of NPs attempt to counsel the majority of their patients about exercise. However, lack of patient interest and the limited duration of visits present significant barriers to counseling patients during primary care visits (Tompkins, Belza, & Brown, 2009). When clinicians encourage patients to increase their physical activity, they primarily do so by attempting to further educate patients and persuade them with logic and reason (Levensky, Forcehimes, O’Donohue, & Beitz, 2007). If a patient is already motivated to change, these tactics may work; however, these conventional methods have been shown to result in positive behavior change in less than 25% of patients (Koelewijnvan Loon et al., 2008).
Patients who do not appear motivated to increase their level of physical activity may be experiencing ambivalence. Ambivalence is a natural stage of the decision-making process—the stage in which it is easiest to become stuck (Miller & Rollnick, 2013). When a patient is ambivalent, he or she is aware of arguments both for and against making a particular decision. As soon as one argument begins to sound convincing, the patient turns his or her focus to the counterarguments. This phenomenon can be summarized as the “yes, but” dilemma (Miller & Rollnick, 2013). A clinician may become aware of a patient’s ambivalence by statements such as, “I know I should start walking, but I’m just so tired.” If the clinician agrees with the behavior change by articulating reasons for change, some clients will naturally begin to articulate the reasons not to change. Arguing for change with an ambivalent client can be counterproductive (Miller & Rollnick, 2013); therefore, clinicians encouraging behavior change need to turn to other tactics.
MI is a method for approaching patients who are ambivalent about making a change, and it has been shown to be more effective than traditional, “advice-giving” conversations (Rubak, Sandbaek, Lauritzen, & Christensen, 2005). MI was developed in 1983 by psychologist William R. Miller as an alternative to the then-dominant style of counseling for addictive behavior, which relied on confrontation and directives. Miller and Rollnick (2013) defined MI as “a collaborative conversation style for strengthening a person’s own motivation and commitment to change” (p. 12).
MI is used in a variety of health care settings, from substance abuse counseling to chronic illness management; it has broad implications for improving any condition in which behavior change plays a significant role. MI has been shown to be effective in patient encounters that last as briefly as 15 minutes (Rubak et al., 2005). The key principle behind MI is that ambivalent patients will not be moved to change their behavior even when a clinician makes a convincing case for change; rather, these patients are more likely to enact a change if they articulate their own reasons for doing so. To accomplish this goal, MI focuses on mobilizing a patient’s internal motivations. Although clinicians can spend years honing their MI skills, MI can be used effectively even by the novice (Madson, Loignon, & Lane, 2009).
MI comprises four processes (i.e., phases) that are generally performed in order but are also recursive (Table 1). The first phase is engaging, which involves forming a working patient–provider relationship. During the second phase (i.e., focusing), the provider and patient settle on an agenda, which is usually a specific behavior change or set of changes that the patient is considering. The third phase of MI is evoking, during which the provider attempts to elicit the patient’s personal reasons for change. The final phase is planning, which occurs when the patient shifts away from the question of whether to change and turns to the questions of how and when the change can occur (Miller & Rollnick, 2013).
The Four Processes of Motivational Interviewing
Throughout all four phases of MI, the clinician asks open-ended questions, makes affirmations, listens reflectively, summarizes, informs, and advises (Table 2). Open-ended questions invite the patient to explore his or her ambivalence, goals, and values. Affirmations are statements that acknowledge the patient as a person of worth, with the autonomy to decide on a change. Reflective statements allow the clinician to make a guess about the patient’s meaning and demonstrate listening. By selectively reflecting the parts of the patient’s statements that articulate reasons for change, known in MI as change talk, the clinician reinforces the patient’s own reasons for change. Summarizing is used to pull together the patient’s various statements and offer them to the patient to promote understanding. The fifth core skill (i.e., informing and advising) is likely to be familiar to NPs. In MI, the clinician shares relevant information about risks, benefits, options, and resources only after the patient provides permission (Miller & Rollnick, 2013).
The Core Skills of Motivational Interviewing
A common barrier to successful implementation of MI is the righting reflex, or the instinctive desire shared by many in health care to prevent harm. This instinct can paradoxically hinder conversations with ambivalent patients when it manifests as telling the patient what to do. Because attempts at persuasion can send an ambivalent patient further in the opposite direction, MI urges clinicians to resist this tendency and instead direct their energy toward guiding the client toward his or her personal reasons for change. Rollnick, Miller, and Butler (2008) stated that if, as the clinician, “you’re arguing for change, you’re taking all the good lines” (p. 8).
Nurse Practitioners and Motivational Interviewing
Part of the NP role is a focus on health promotion and preventive care; as such, NPs are in a prime position to promote physical activity for older adults. NPs tend to maintain a holistic perspective that considers treatment within the context of an individual’s overall well-being (Sustaita, Zeigler, & Brogan, 2013). Studies indicate that when NPs use communication styles that actively engage patients in generating ideas and making decisions, the result is increased patient satisfaction and adherence to treatment plans (Charlton, Dearing, Berry, & Johnson, 2008). Because MI is most effective when performed over a series of visits (Rubak et al., 2005), NPs who see patients regularly for chronic disease management are particularly well-positioned to use MI to promote change.
Motivational Interviewing to Promote Physical Activity
MI’s focus on the individual patient’s values and goals results in a truly individualized plan. Because the type of exercise is less important than maintaining regular physical activity, the provider can use MI to explore the patient’s values and goals to increase motivation and develop a plan that will work for the patient. Unlike other behavior changes in which a specific behavior is in question (e.g., medication adherence), increasing physical activity is a general goal that provides the patient and provider with the latitude to explore what changes are truly feasible for the patient.
Motivational Interviewing for the Older Adult Population
A substantial body of research exists regarding the effective use of MI for weight loss, chronic disease management, and increasing physical activity in the adult population (Rubak et al., 2005; Thompson et al., 2011). Researchers are beginning to explore the effectiveness of MI among the older adult population, with studies focusing on weight loss, diabetes management, physical activity, and dietary adherence. A review conducted by Cummings, Cooper, and Cassie (2009) found MI to be more successful than traditional counseling at instigating behavior change in older adults. Evidence exists that MI is effective in promoting physical activity in older adults with chronic diseases, including heart failure (Brodie & Inoue, 2005), diabetes, obesity, and cancer survivorship (Cummings et al., 2009). MI emphasizes that the individual is an expert on him- or herself, which is particularly relevant to older adults, who have had decades to learn about what works for them and develop habits and routines. Through open-ended questions, reflections, and summaries, NPs can help patients explore how these internal and external factors are affecting their motivation to increase physical activity.
Promoting Physical Activity Using Motivational Interviewing: A Sample Dialogue
The following dialogue is a sample fictional conversation with Diane, the 72-year-old woman with type 2 diabetes. It is intended to demonstrate how MI could be used to promote physical activity in an older adult patient. Notes on how the clinician’s conversational style fits the MI model are shown in italics. The process of engaging with the patient has already been completed as the conversation begins.
NP: Given your concerns about your energy level, I’m wondering if you’d like to talk about how you’re doing with getting physical activity. (Emphasizing autonomy by asking permission.)
Diane: Oh, I knew I wasn’t getting out of here without the exercise lecture. Go ahead.
NP: I promise not to lecture you. I’m curious how physical activity is fitting into your life these days. (Open-ended question.)
Diane: Well, it isn’t. I’m watching my grandson, Cameron, every day, and every time I think to get out and walk, it’s 20 degrees below and I can’t stand the idea of making my back and knees hurt worse than they already do. I know I should exercise, but I’m just not. (A “yes, but” statement indicating ambivalence. This passage includes both change talk [i.e., “I know I should exercise”] and statements that support the status quo [i.e., sustain talk].)
NP: It’s proving challenging, but you want to get out there. (Reflection focusing selectively on the change talk.)
Diane: I do. I know that sitting around all day doesn’t help anything. (Change talk.)
NP: You know the value of exercise. What do you imagine it doing for you? (Reflection of the change talk, followed by an open-ended question.)
Diane: Well, I know it could help with my blood sugar, maybe keep the weight from piling on. But my knees aren’t making it any easier, and I’m just so tired after Cam goes home. (Identifying reasons for change, which is a type of change talk, followed by sustain talk.)
NP: It must be hard to keep up with the little guy! You’re so devoted to him. (Affirmation.)
Diane: Oh yes! He has a way of making me feel young and really old at the same time.
NP: Being with him makes you aware of how your health has changed. (Reflection [i.e., selectively focusing on what may be a reason for change].)
Diane: Very much so. I’ve slowed way down. I don’t know how I’ll keep up once he gets bigger, but he’s my whole world. (Articulating values.)
NP: He brings a lot of meaning into your life, and you wonder how you can be sure you’ll be there for him in the future. (Reflection.)
Diane: Sort of. I mean, I know I’ll be there for him, but I don’t know what kind of shape I’ll be in, you know? (A mild correction to the provider’s reflection. A reflection is simply a guess at the patient’s meaning, and there is no harm in getting it wrong.)
NP: You have some health issues that concern you, and you wonder how they’ll affect your ability to take care of yourself and Cameron. (Reflection, connecting values to the area of concern and possible behavior change.)
Diane: Exactly, which I suppose gets us back to all the things I ought to be doing. I’ll bet you wish I was pumping iron and running stairs at the stadium.
NP: It’s not at all up to me what sort of physical activity you do, if any, but I’m here to support you if this is something you’d like to address. I am noticing that your concerns about fatigue and joint pain are actually issues that might be helped by exercise. Would you like to hear more about that? (Reinforcing autonomy by emphasizing that a change is the patient’s decision alone, and asking permission before giving information.)
Diane: Go on.
NP: Regular exercise can actually reduce the arthritis pain in your knees, and if exercise helps you lose a few pounds, that would help, too. Although it’s a little counterintuitive, more exercise could help you feel more energized during the day. What do you think about that? (Providing information, followed by an open-ended question.)
Diane: I see what you’re getting at. I guess I’m all out of excuses then.
NP: The decision to take this up is completely up to you. How would you see more exercise fitting into your life? (Reinforcing autonomy, followed by an open-ended question.)
Diane: It’s hard to imagine how to fit it in when I haven’t managed to yet, but I can see how some regular exercise would be something I’d be doing for both me and Cam. I could sure use more energy. (The patient is articulating her own reasons for change.)
NP: You’d love to have more energy, but you are wondering about how to make it happen now. What do you see as the biggest potential pitfall? (Complex reflection on the change talk, followed by an open-ended question.)
Diane: By the time Cam leaves, I’m ready to put my feet up, but I suppose there’s the morning. (Sustain talk, followed by change talk.)
NP: Getting in some activity first thing in the day might work for you. (Reflection.)
Diane: I usually feel pretty good then, but what would I do? I don’t want to join a gym.
NP: You’d be looking for a way to exercise outside of a fitness center. (Reflection.)
Diane: Exactly. Walking is good—it’s more interesting. It’s so cold though, but I suppose I could walk indoors. That big mall is nearby, and it might be a good chance to talk to people while I walk.
NP: It sounds like that might work for you, and it fits with what kind of grandmother you’d like to be. How likely is it that you’ll try this in the next week? (Reflection, looking for level of commitment.)
Diane: I’d say pretty likely. I’m actually kind of excited about this. (Some commitment.)
NP: Well that’s great. You’ve certainly put a lot of thought into this. To summarize, you’ve been thinking about how getting some regular physical activity into your life could help relieve some pain and fatigue. At times, it’s been hard to exercise, especially when it’s cold, but you want to be able to take care of Cameron into the future, and it seems that walking in the mall in the mornings, before he arrives, could work for you. Should we schedule a follow up in a month to see how it is going? (Affirmation, then a summary.)
Diane: Yes, that sounds good. I bet I can start this week.
Reflection on the Dialogue
In this example dialogue between a patient and an NP, the NP guides the patient, Diane, to explore her ambivalence about physical activity. Diane is considering adding more activity to her days, believing that doing so will increase her level of energy; however, she has already thought of multiple reasons why increased activity will be a challenge. The clinician’s response to Diane’s ambivalence demonstrates the core of MI. At no point did the clinician directly tell the patient what to do. The clinician did not lead the patient through the discussion, nor follow passively behind; instead, the clinician acted as a guide, gathering information about the patient’s challenges and goals and, at times, making subtle connections between those goals and the patient’s values. The clinician used reflections to test the understanding of the patient’s meaning, asked permission to provide information, and reinforced patient autonomy. The clinician provided the patient with enough space in the conversation to come up with her own solution, which she will ultimately be responsible for implementing.
MI allows NPs to address the common problem of health behavior change with a patient-centered approach. NPs and patients may find these conversations more enjoyable and collaborative rather than repeated attempts at patient education or reasoning. By using MI, NPs can continue to build strong patient–provider relationships, while also supporting health promotion and disease prevention.
Physical activity is an integral component of health maintenance and disease prevention at all ages. Regular physical activity in older adults can prevent or lessen the burden of many chronic diseases, as well as protect against falls, activities of daily living disability, and cognitive decline, all of which contribute to maintaining independence later in life. Encouraging behavior change within the limited time frame of a primary care appointment is often challenging, especially when a patient feels ambivalent about the change; however, MI is an evidence-based intervention that can help. MI’s insistence that the patient is the ultimate expert on him- or herself respects the life experience of older adults, whereas the wide range of acceptable ways to increase physical activity allows the provider and patient latitude to develop a truly individualized plan. The professional focus of the NP on prevention, holistic health, and education makes NPs uniquely well-suited to use MI to address physical activity among older adults within primary care.
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The Four Processes of Motivational Interviewing
||The provider and patient establish a working relation-ship. The provider makes it clear that he or she is not there to tell the client what to do.
||The patient–provider dyad settles on an agenda. The provider maintains patient autonomy by focusing on the patient’s most pressing concern.
||The provider elicits the patient’s personal reasons for change. When done successfully, the patient will be voicing the arguments for change.
||This phase is marked by the shift from the “why” of change, to the “when” and “how.” The provider guides the patient to come up with the best options for him- or herself.
The Core Skills of Motivational Interviewing
|Asking open-ended questions
||Inviting the patient to explore his or her ambivalence, challenges, goals, and values.
||“How do you think you’d benefit from being more physically active?”
||Acknowledging the patient as a person of worth with the capability to change and the autonomy to decide on a change.
||“This wouldn’t be the first obstacle you’ve overcome. You’re a hard worker.”
||Demonstrating the intent to truly understand what the patient is conveying, including attempting to guess the patient’s meaning.
||“You’re not sure where to start.”
||A way to pull together the patient’s various statements, and then offer them back to the patient in an organized fashion.
||“You’ve come to the point where you know it’s time to get serious about your health. You know that you and your grandchildren will benefit. Although you’re wary of the physical challenge, you could get excited about joining a walking group.”
|Informing and advising
||Providing information, with the patient’s permission.
||“If you’d like, I can give you examples of what has worked for some other individuals with your condition.”