Dr. Rash is Assistant Professor, College of Nursing, University of Central Florida, Orlando, Florida.
Address correspondence to Elizabeth M. Rash, PhD, ARNP, FNP-C, Assistant Professor, College of Nursing, University of Central Florida, PO Box 162210, Orlando, FL 32816; e-mail: email@example.com.
The purpose of this article is to describe a motivational interviewing application exercise developed for a graduate-level online health promotion course. The American College of Nurse Practitioners and the American Academy of Nurse Practitioners have identified health promotion as a primary function of advanced practice nurses (Berry, 2006). However, nurses frequently view health education and health promotion as synonymous terms (Cross, 2005). Although advising and providing information may be preferable to not addressing health promotion issues, unilateral decision making and provider-centered care are less successful strategies than patient-centered shared decision making efforts toward behavioral change (Eberman, Patten, & Dale, 1998).
Motivational interviewing, a successful approach used for addictions treatment, has come to the forefront in primary care as a method of helping patients make healthier lifestyle choices (Waldrop, 2006). Motivational interviewing is designed to resolve patient ambivalence and build motivation for behavioral change through patient-directed, provider-guided change talk. Key principles include listening reflectively; building self-efficacy; developing discrepancy; recognizing readiness to change; rolling with, rather than arguing against, resistance; and asking open-ended questions (Miller & Rollnick, 2002). Motivational interviewing is an integration of these specific communication skills, along with a global spirit of caring and genuineness. Miller and Rollnick suggested that acquisition of motivational interviewing techniques requires repeated provider practice and role-play.
Objectives of our master’s-level health promotion course include exploring and applying theory and evidenced-based knowledge to promote healthy individuals and communities. This course is one of the core requirements for our master’s nurse practitioner, clinical nurse specialist, and nursing education tracks sequenced toward the beginning of the program of study. The course is offered online 3 times per year and includes a variety of content ranging from individual preventive guidelines to community and global health promotion issues. As students are typically not taking concurrent clinical courses, the online format presents a challenge in allowing students to apply their understanding of these theoretical and evidenced-based concepts.
During the first few weeks of the semester, students develop an understanding of health promotion at the individual, community, and global levels, evidenced-based prevention guidelines, and health risk appraisal tools. Students complete their own health risk appraisal and then take a WebCT® self-evaluation survey. This survey was developed by the course instructor, is consistent with many motivational interviewing techniques, and guides students to identify and prioritize their values, behavioral change needs, self-efficacy, and motivation for change. The survey also asks them to identify potential barriers and facilitators to change and their readiness for behavioral change. Because students’ surveys are read by the instructor and are shared with a classmate, students are told to limit their self-disclosures to issues they feel comfortable sharing with others.
At the conclusion of the survey, students are asked to reflect on the usefulness of performing this kind of self-evaluation. Students remarked on the benefits of identifying their values and behavioral discrepancies, seeing their behavioral change needs in writing, and recognizing that they need to be involved in self-care to care for others as nurses.
The students then examine a variety of behavioral change and health promotion theories and models, including the Transtheoretical model (Prochaska & DiClemente, 1992), the Health Promotion model (Pender, Murdaugh, & Parsons, 2006), and motivational interviewing (Miller & Rollnick, 2002). Students were asked to identify the model or theory that best aligns with their beliefs and practices and to describe a patient care situation during which they have applied or might apply this approach.
Students were then directed to self-select small groups with two other classmates for the purpose of a brief intervention role-play using motivational interviewing skills. They were told that the role-play would take place in a synchronous online environment using the WebCT chatroom tool. Members of each group had to agree on three separate 20-minute time segments within a 2-week period in which they would all be available to participate in this role-play. These times were then submitted to the instructor for the purposes of creating a master schedule that prevented groups from overlapping in the four available chatrooms. In addition, group members were to identify who would play the roles of patient, health care provider, and peer reviewer in each session. Students rotated roles for each session.
Preparation instructions for the role-play sessions included students sharing their completed self-evaluation survey with the group member who would play their health care provider during the specified session, and reviewing selected motivational interviewing resources. During the role-play, the student health care provider was to use motivational interviewing skills to assist the student patients in overcoming their ambivalence to change and move toward healthier behaviors. Students playing the role of the peer reviewer were to listen or read silently during that segment of time and then complete a peer review form about the observed interaction. At the completion of the sessions, this form was shared with the other students and submitted to the instructor.
Students were graded on preparation for their roles and attempted application of motivational interviewing skills in the health care provider role, submission of the peer review form, and reflections of the overall exercise and their personal performance. The WebCT chatroom tool allows the instructor to view saved copies of the transcripts of each session. This accessibility permitted students to select time segments not dictated by the instructor and without the instructor’s presence during the sessions. Undoubtedly, the instructor’s presence would have influenced student sessions. However, the instructor used the transcripts to assess student preparation and skill application and to provide the students with personalized feedback.
As reported by Miller and Rollnick (2002), practice is required to become proficient in motivational interviewing. Therefore, instructor evaluation of the transcripts focused on effort, rather than on precision, whereas students’ self-reflections and peer reviews revealed their depth of understanding of the motivational interviewing process.
Overall, the application exercise was well received by students and demonstrated an appreciation for motivational interviewing. Students acknowledged the need to practice motivational interviewing skills to develop their proficiency and thought the online chat expanded their understanding beyond what they might have gained simply through reading the materials. Students expressed awareness that traditional provider-directed patient education could be considered as patronizing and that motivational interviewing was less likely to create patient resistance and more likely to support the patient’s behavioral change, whether the patient was in a precontemplation or an action phase. One student was taken off guard when her student patient decided to address a topic not included in his self-evaluation. However, that student remarked that “motivational interviewing came to her rescue” and the interaction went more smoothly than she had anticipated.
In addition, some students remarked that the experience truly motivated them to improve their lifestyle behaviors; for example, some started walking in the evening with their spouse or improved their personal relationship interactions. One student stated that her use of motivational interviewing skills with her college-age daughter helped them avoid arguing, was productive, and included one of the best discussions they had ever experienced together.
Students were also asked to provide recommendations for improving this exercise. Almost unanimously, students identified the allotted time of 20 minutes as insufficient to establish rapport and motivate change. This time frame was chosen to represent a brief intervention in a clinical setting. However, the time required for typing and visually processing responses was not accounted for, and 20 minutes in a chatroom is more likely representative of 10 minutes in a clinical setting.
Although it was suggested that students allow for time between sessions to reflect on their interactions, it was not required. The majority of students chose, probably for reasons of convenience, to conduct the sessions back-to-back within a 1-hour time frame. Many of these students expressed that this was a poor choice because they did not have the opportunity either to reflect or to transition to their next role.
Despite these comments, synchronous distance learning is not the norm at our university, and there is some reticence to be more prescriptive regarding time segments. However, future students will be instructed that they may go beyond minimum time segments and the benefit of intermissions between sessions will be emphasized.
One student revealed that she thought she “could have been trying too hard to follow the [motivational interviewing] techniques for the purpose of a grade…trying to pack too much in at one time” and that despite the relative safety of the online role-play, she felt anxious and had prepared a script for the session. I suspect that given the relative proficiency observed in the transcripts, other students prepared similarly. Although this does demonstrate some level of learning, the intent of the exercise was to mirror application in a live clinical setting. Thus, the grading rubric will be revised to deemphasize the acquisition of motivational interviewing skills and to concentrate instead on the process of assisting patients with behavioral change.
Other students identified the disadvantage of not having intonations and facial expressions to assist them in expressing their genuine empathy. One student thought that having the self-evaluations before the session was an unrealistic advantage. However, the self-evaluations likely facilitated rapport and insight that previous visits or chart documentation may generate in a clinical setting. In addition, the self-evaluation provided students with an early introduction to motivational interviewing.
This class activity reinforced that patient interaction skills can be simulated in an online environment. In addition, and perhaps more important, the application exercise using motivational interviewing skills allowed students to realize that health promotion is more than providing information. The application exercise also appeared to create a paradigm shift in students’ perceptions of health promotion.
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- Cross, R2005. Accident and emergency nurses’ attitudes towards health promotion. Journal of Advanced Nursing, 51, 474–483. doi:10.1111/j.1365-2648.2005.03517.x [CrossRef]
- Eberman, KM, Patten, CA & Dale, LC1998. Counseling patients to quit smoking. What to say, when to say it, and how to use your time to advantage. Post Graduate Medicine, 1046, 89–94.
- Miller, WR & Rollnick, S. 2002. Motivational interviewing: Preparing people for change (2nd ed) New York: Guilford.
- Pender, NJ, Murdaugh, CL & Parsons, MA2006. Health promotion in nursing practice (5th ed) Upper Saddle River NJ,: Prentice Hall.
- Prochaska, JO & DiClemente, CC1992. Stages of change in the modification of problem behaviors. Progress in Behavior Modification, 28, 183–218.
- Waldrop, J. 2006. Behavior change in overweight patients. Motivational interviewing as a primary care intervention. Advance for Nurse Practitioners, 14 (8), 23–27.