Motivational Interviewing for Increasing Physical Activity
By now you have learned about the basics of physical activity, guidelines, and the many benefits of physical activity. You may be wondering, though, how can we motivate patients to become more physically active?
For some people becoming and staying physically active is not easy. How can we inspire patients to become more physically active? One way is through a counselling style called Motivational Interviewing which will be explained in detail in this module.
What is Motivational Interviewing?
Motivational Interviewing is a behaviour change counselling technique that is a collaborative effort involving you—the nurse—and the patient. In particular, it strengthens motivation and commitment to make behavioural changes.1
The responsibility of behaviour change is put on the patient, with you acting as a facilitator for the patient to become more physically active.
Motivational Interviewing has
been found to be effective for
motivating behaviour change
since the inspiration, ultimately,
comes from inside the patient
rather than through the coercion
of someone else. Everybody who
advises patients on health
behaviours can use techniques
from Motivational Interviewing
– you don’t have to be a
psychologist to use these strategies.
Fast Fact: Motivational Interviewing was first described in 1983 by William R. Miller as a method used for treating problem drinkers. Since then, more than 200 intervention studies have examined the utility of Motivational Interviewing for facilitating health behaviour change for a wide variety of applications from illicit drug abuse to increasing physical activity.1
The Spirit of Motivational Interviewing: The Basics of the Technique2
Collaboration
When you are following Motivational Interviewing techniques, physical activity counselling is viewed as a partnership between you and the patient. Collaboration facilitates the building of good rapport and diminishes resistance in the relationship between you and the patient.
Evocation
The goal of Motivational Interviewing is to “draw out” the patient’s thoughts and feelings surrounding physical activity rather than impose your own beliefs. Motivation and commitment to become more physically active is stronger when it comes from the patient rather than from someone else who offers advice and ideas.
Autonomy
Patients are more likely to be receptive to physical activity counselling if they feel autonomous (i.e., that they are in control) of decisions. Autonomy can be fostered by providing choices and being cautious not to impose your own opinions and suggestions.
Principles of Motivational Interviewing: Some Tips for Getting Started2
Express Empathy
From a Motivational Interviewing standpoint, when working with a patient, it is advisable to see things from the patient’s unique point of view (empathy). What is it like for that patient to try and be more active? What kinds of challenges does the person face?
Conveying empathy builds a rapport and makes it more likely that patients will be open in sharing thoughts and experiences with you.
Support Self-Efficacy
In order for patients to be successful in becoming more physically active, they must first be confident (have high self-efficacy) that they can make these changes. For many patients, repeated failed attempts to become more physically active make them doubtful that they are capable of leading an active lifestyle.
Part of Motivational Interviewing involves supporting self-efficacy. This can be accomplished by helping the patient think about other challenges that have been overcome or by highlighting his or her skills and accomplishments.
Roll with Resistance
Resistance by patients can occur in response to suggestions or advice that you give. It is normal to want to be helpful and give suggestions regarding physical activity. Unfortunately, often patients react to these suggestions by using arguments that begin with “yes, but…” or by taking a “devil’s advocate” approach of arguing for reasons why they can’t become more active.
The danger is that the more patients argue for why they cannot change, the greater the likelihood that they will not take positive steps to become more physically active. The way to avoid counterproductive argumentation is to roll with resistance (i.e., avoiding “arguing” with the patient by advice giving or by passing judgment). Consider changing the topic or accepting the resistance without further argument. Below is an example of a dialogue between a nurse and patient in which the patient indicates resistance yet the nurse fails to “roll with it” and continues to offer advice.
Sample Script of Nurse Failing to “Roll with Resistance”
Nurse: Tell me a little bit about your physical activity level.
Patient: Um, I have to admit I am not really doing a lot of exercise right now. It is really hard to fit it in between all my appointments and other things I have to do. Plus I am really tired most of the time (demonstrating resistance).
Nurse: What about if you exercised before you went to work in the morning? That would probably make you feel less tired too.
Patient: Oh, I can’t do that, I am really not a morning person. Besides, my workday starts at 7:30 am.
Nurse: Well what about on your way home from work, maybe you could stop at the YMCA? Exercising is really important in order to stay healthy.
Patient: I have to pick up my kids right after work so that really wouldn’t be possible either. I am really just too busy to exercise right now.
As you can see, failing to roll with resistance can result in the patient arguing further for why she cannot become more physically active. At the end of this module, there is an example of a discussion with the same patient. This time though the nurse uses a Motivational Interviewing approach that involves rolling with resistance rather than direct advice giving.
Develop Discrepancy
According to Motivational Interviewing principles, physical activity behaviour change can occur when patients realize a lack of connection between what they feel they should be doing and what they are doing. They may then take steps to sort through this ambivalence. This is very common. Many people are aware of the health and other benefits of physical activity and feel they should be more physically active, yet they are not physically active.3
It is very important not to impose your own beliefs on the patient concerning strategies for becoming more physically active, but rather to facilitate this process.
Tips for Using Motivational Interviewing for Physical Activity Counselling2
By reviewing some of these techniques, you will be able to implement various Motivational Interviewing strategies into your work with patients. Other more specific strategies will be detailed in the next module (Module 4).
OARS: An acronym that outlines the basic Motivational Interviewing approach.
Open-ended questions
Open-ended questions are questions that elicit a response that is not a “yes”, “no”, or a simple short answer. When using Motivational Interviewing techniques, you will want, primarily, to use open-ended questions since they prompt exploration of ideas and further open discussion about physical activity.
- An example would be asking “What are your thoughts about adding more physical activity to your daily routine?” Consider the effect of this kind of questioning over that of the following question, “Would you be interested in starting a physical activity program?”
Affirmations
Affirmations involve acknowledging effort and accomplishments the patient has made concerning health behaviour change. Affirmations help foster self-efficacy as well as build rapport. An affirmation could simply be praising the patient for starting to think about ways to increase physical activity or success in other health behaviour change such as quitting smoking.
Reflective listening
Reflective listening refers to a counselling technique central to Motivational Interviewing that involves reflecting themes and individual phrases back to the patient. Reflective listening not only shows patients that you are really listening to them, it also helps patients recognize and sort through the discrepancy of believing they should be more physically active while facing challenges to initiating change.
- An example of reflective listening is illustrated in this example:
- Patient: I know I should start exercising more. Heart disease runs in my family and I really don’t want to get that. Also, my sister was just diagnosed with diabetes, but she is older than me and much more of a couch potato than I am. Still, sometimes I worry that I am at risk too.
- Nurse: It sounds like given your family history there might be some good health reasons for becoming more active.
Summarize
Summarize is a type of reflective listening that involves summarizing the whole or part of a counselling session. Summarizing helps to recap the session as well as draw attention to important elements of the discussion. For example, you could try highlighting a theme concerning a prominent barrier or point of motivation that emerged throughout the discussion. By doing this, the patient may see its relevance to initiating and maintaining regular physical activity.
Eliciting Change Talk
An important step in the behaviour change process is that the patient needs to indicate change talk. Change talk occurs when the patient uses phrases such as “I really should start exercising,” “I think I could manage going to the gym a couple of times of week after work,” or “I think I am going to try taking a walk after dinner.” Typically, hearing change talk signifies that the patient is starting the process of becoming more physically active.
A Sample Script of Motivational Interviewing:
Nurse: Tell me a little bit about your physical activity level.
Patient: Um, I have to admit I am not really doing a lot of exercise right now. It is really hard to fit it in between all my appointments and other things I have to do. Plus I am really tired most of the time (demonstrating resistance).
Nurse: It does seem like you are very busy right now, and it is completely understandable that you are tired given you are in the middle of radiation therapy (reflective listening, expressing empathy).
Patient: Maybe when things settle down a bit I might start walking again. I used to like taking my walks.
Nurse: Walking is great exercise (affirmation)! Tell me more about that (open-ended question).
Patient: I used to take a walk almost every night with a friend of mine. We used to walk about a mile or so, even in the winter! It was really nice because we used to talk and I found it just, you know, relaxing after a stressful day.
Nurse: That does sound nice. What made you stop doing it?
Patient: I don’t know, maybe we just got busy. I should really call her, but then I don’t know if I would have time to walk every day.
Nurse: I’m sensing that you would like to start walking with your friend again, but on the other hand you feel things are pretty hectic right now, am I reading this right (developing discrepancy)?
Patient: Yeah, that’s about right.
This script illustrates the first part of a discussion on physical activity with a patient. At this point, the nurse has effectively started to develop discrepancy, which is the first step in motivation for behaviour change. Compare this to the script you read earlier in the module that illustrated a nurse not rolling with resistance with the patient.
Key Points:
- Motivational Interviewing is a collaborative counselling approach.
- Principles include develop discrepancy, support self-efficacy and roll with resistance.
- Use OARS (Open-ended questions, Affirmations, Reflective listening, Summarize) as the backbone for effective Motivational Interviewing.
- One of the beginning steps is to elicit change talk (dialogue that indicates the patient is ready, confident or willing to change physical activity levels).
From this module you will have gained a better understanding of Motivational Interviewing concepts that you can use when providing physical activity counselling. In the next module, we will explore specific strategies rooted in Motivational Interviewing that help inspire physical activity participation as well as show videos demonstrating Motivational Interviewing compared to a non-motivational counselling approach.
Please click on the link below to start the quiz.
References
- Miller WR, Rose GS. Toward a theory of Motivational Interviewing. Am Psychol. 2009;64, 527-537.
- Wagner CC, Motivational Interviewing Network of Trainers (MINT), Miller WR, Rollnick S. Motivational interviewing: Background information. Retrieved September 3, 2015 from: http://www.motivationalinterview.net/clinical/overview.html.
- Vallance JK, Courneya KS. Social cognitive approaches to understanding exercise motivation and behavior in cancer survivors. In: Roberts GC, Treasure DC, eds. Advances in Motivation in Sport and Exercise. Champaign, IL: Human Kinetics; 2012:299-326.
- Martins RK, McNeil DW. Review of Motivational Interviewing in promoting health behaviors. Clin Psychol Rev. 2009;29:283-293.
- Hardcastle SJ, Taylor AH, Bailey MP, Harley RA, Hagger MS. Effectiveness of a motivational interviewing intervention on weight loss, physical activity and cardiovascular disease risk factors: a randomised controlled trial with a 12-month post-intervention follow-up. Int J Behav Nutr Phys Act. 2013;10:40.