Public Health Nursing Vol. 18 No. 3, pp.

178–185
0737-1209/01/$15.00
䉷 Blackwell Science, Inc.

The Art of Motivating Behavior

Change: The Use of
Motivational Interviewing to
Promote Health
Harold E. Shinitzky, Psy.D., and
Joan Kub, Ph.D., R.N., C.S.

INTRODUCTION
Abstract Health promotion and disease prevention have always
been essential to public health nursing. With the changing health With the changing health care system and an increased
care system and an increased emphasis on cost-containment, the emphasis on cost-containment, the role of the nurse is
role of the nurse is expanding even more into this arena. A expanding more and more into the arena of health promo-
challenge for public health nurses, then, is to motivate and facili- tion. In 1986, the First International Conference on Health
tate health behavior change in working with individuals, families, Promotion was held in Ottawa, Canada. This conference
and communities and designing programs based on theory. Lead-
has served as a source of inspiration for health promotion
ing causes of death continue to relate to health behaviors that
require change. The purpose of this article is to integrate theory
since that time. Five levels of action were outlined: (1)
with practice by describing the Transtheoretical Model of Change building health public policy, (2) creating supportive envi-
as well as the principles of motivational interviewing that can ronments, (3) strengthening community action, (4) devel-
be used in motivating behavioral change. A case scenario is oping personal skills, and (5) reorienting the health system
presented to illustrate the use of the models with effective inter- (World Health Organization [WHO], Health and Welfare
viewing skills that can be used to enhance health. Implications for Canada, and the Canadian Public Health Association,
practice with an emphasis on providing an individually tailored 1986). It is increasingly recognized that action on all of
matched intervention is stressed. these levels is necessary for a comprehensive approach to
Key words: Transtheoretical Model, motivational inter- health. Influences on health occur at several levels includ-
viewing, health promotion, health behavior. ing individual, interpersonal, community, environmental,
and health care system (Donatelle & Davis, 1998).
Health promotion strategies, which influence an individ-
ual or population, may be either active or passive. Passive
strategies involve the client as an inactive participant and
include approaches such as maintaining clean water. Active
strategies on the other hand, depend on the individual
becoming personally involved in adopting a proposed pro-
gram of health promotion that might include exercise regi-
mens or decreasing daily calories (Edelman & Mandle,
Harold E. Shinitzky is an Instructor, Department of Pediatrics, 1998). Personal health behavior began to attract attention
Johns Hopkins University, School of Medicine, Baltimore, Mary- in the 1960s, with the release of the First Surgeon General’s
land. Joan Kub is an Assistant Professor, Johns Hopkins Univer- Report on Smoking and Health. Since that time other areas
sity School of Nursing, Baltimore, Maryland.
Address correspondence to Harold E. Shinitzky, 2531 Land- of human behavior, such as dietary patterns and physical
mark Dr., Suite 203, Clearwater, FL 33761. E-mail: hshinitz@ activity, have been subjects of major Surgeon General’s
jhmi.edu Reports (Lee & Estes, 1997).

178
 Shinitzky and Kub: Motivating Behavior Change 179

As outlined in the Ottawa Charter, we seek to explore stages of change, processes of change, and levels of change
the role that nurses can play in promoting and developing (DiClemente & Prochaska, 1998).
personal skills leading to healthier clinical outcomes. This
is not to negate the importance of the other skills, but it Stages of Change
is increasingly recognized that behavioral determinants of The stages of change consist of five categories along a
health are contributing factors of premature death. These continuum that reflect an individual’s interest and motiva-
leading causes of death in order of priority are tobacco, tion to alter a current behavior. It is through movement
diet and activity, alcohol, microbial agents, toxic agents, along these stages that one is able to achieve successful
firearms, sexual behavior, motor vehicles, and the illicit behavioral change (DiClemente & Prochaska, 1998). These
use of drugs (McGinnis & Foege, 1993). stages include precontemplation, contemplation, prepara-
A challenge for public health nurses then, is to motivate tion, action, and maintenance. Each health care provider
and facilitate health behavior change. Effective interper- must determine the readiness to change or the stage in
sonal skills are essential techniques that can be used to which each patient is in prior to developing a treatment
accomplish this task. Enhancing the interpersonal commu- plan.
nication skills of health providers results in increased levels
of satisfaction among clients and providers, greater adher-
1. Precontemplation is the stage in which there is an
ence to treatment regimens, fewer lawsuits, continuity of
unwillingness to change a problem behavior or there is
the same provider, and better follow-up on appointment
a lack of recognition of the problem. If a patient is not
keeping (Hall, Roter, & Tand, 1988; Levinson, Roter, Mul-
thinking about any behavior change in the next 6
looly, Dull, & Frankel, 1997; Wissow et al., 1998; Haynes,
months, she or he is classified as a precontemplator.
1976). 2. Contemplation involves the stage in which there is a
Noneffective encounters often result in barriers to opti- consideration of change with a decision-making evalua-
mal care. Although most patients are able to identify ap- tion of the pros and cons of both the problem behavior
proximately three to four issues that they would like to and the change. Individuals frequently begin to weigh
address with their health care provider, one study revealed the consequences of action or inaction. At this point,
that the average health care provider interrupts his or her patients are able to discuss the negatives as well as the
patients’ disclosures after 18 seconds (Beckman & Frankel, benefits associated with the at-risk behavior. This opens
1984). Post visit research has also revealed that 30 to the door to a collaborative process. Usually, these pa-
60% of medical information discussed in an encounter is tients discuss actually changing their current behavior
forgotten, and 50% of medical treatment regimens are not within a 6-month period.
followed to their fullest extent (Haynes, Taylor, & Sackett, 3. Preparation represents the period when there is a com-
1981). mitment to change in the near future, usually 1-month.
Our role as effective health care providers must include Patients express a high degree of motivation towards
then, an understanding of the interpersonal skills that can the desired behaviors and outcomes. Patients in the
be used to motivate individuals to move towards optimal preparation stage have determined that the adverse costs
health. The purpose of this article is to integrate theory of maintaining their current behavior exceed the bene-
with practice by describing one model, the Transtheoretical fits. Therefore, initiating a new behavior is more likely.
Model of Change, that can guide nurses in facilitating These patients have moved from thinking about the
change and to further discuss principles of motivational issue to doing something about it.
interviewing that can be used in facilitating this change. 4. The fourth stage, Action, is when change or modifica-
tion of behavior actually takes place.
Transtheoretical Model of Change 5. After 3 to 6 months of success, the last stage of Mainte-
The Transtheoretical Model of Change, which consists of nance is begun. During this stage, there is a focus on
five stages, has emerged from the research efforts of Carlo lifestyle modification in order to avoid relapse and to
DiClemente and James Prochaska over the past 18 years. stabilize the behavior change (Cassidy, 1997; DiClem-
Most of the research has focused on smoking cessation, ente & Prochaska, 1998).
but the model has also been applied to other addictive
behaviors including drug abuse, obesity, eating disorders, Processes of Change
gambling, exercise, and condom use (DiClemente & Pro- The processes of change facilitate movement through the
chaska, 1998). In the model, intentional behavior change stages of change. There are 10 processes that have been
is emphasized as opposed to societal, developmental, or identified that are responsible for movement (DiClem-
imposed change (Prochaska, DiClemente, & Norcrass, ente & Prochaska, 1998). Five of these processes, which
1992). The three organizing constructs of the model are include consciousness raising, dramatic relief, environ-
180 Public Health Nursing Volume 18 Number 3 May/June 2001

mental reevaluation, social liberation, and self reevaluation, helpful (Prochaska et al., 1992); (Prochaska & DiClemente,
are experiential or cognitive processes. These are internally 1983).
mediated factors that are associated with an individual’s
emotions, values, and cognitions (Cassidy, 1997). Con- Levels of Change
sciousness raising is described as encouraging individuals
Clinicians recognize that individuals have multiple prob-
to increase their level of awareness, seek new information,
lems that often overlap. Addiction, for example, may be as-
or to gain an understanding about a problem. Dramatic
sociated with marital problems, financial problems,
relief is experiencing and expressing feelings about one’s
personality disorders, depression, and violence. With this
problems. Environmental reevaluation is assessing how
recognition, the Transtheoretical Model of Change incorpo-
one’s problem affects the physical environment. Social
rates five levels of change for consideration. These include
liberation is increasing alternatives for nonproblem behav-
changes that relate to the symptoms or situations, maladap-
iors in society. Self reevaluation is assessing how one feels
tive cognitions, interpersonal problems, family/systems
and thinks about oneself in relationship to the problem
problems, and intrapersonal conflicts. Treatment outcomes
(Prochaska et al., 1992).
are often better when a patient’s multiple problems are ad-
The five other processes (counter conditioning, helping
dressed (DiClemente & Scott, 1997). Understanding the life
relationships, reinforcement management, stimulus con-
context of our patients increases the probability that treat-
trol, and self-liberation) are behavioral processes (Pro-
ment plans will fit their overall needs and be individually
chaska et al., 1992; Cassidy, 1997). Counter conditioning
tailored. If we enter into this relationship with the belief
is substituting alternatives for problem behaviors. An ex-
that we are to assess, diagnose, and treat only the most
ample might be the use of meditation to cope with unpleas-
obvious issue, we are likely to overlook other important
ant emotions (Cassidy, 1997). Helping relationships are
issues. If we remain open to the multiple factors impacting
defined as those that provide trust, acceptance, and support.
our patients’ lives, however, we are apt to be inclusive
The provider that listens when there is a need to discuss
rather than exclusive of potential issues.
the problem is an example of this process. Reinforcement
management is the use of positive reinforcements and ap-
Research Findings
propriate goal setting with the patient. Stimulus control is
helping the patient to restructure the environment so that Support for the Transtheoretical Model of Change has been
the stimuli or triggers for the undesired behavior are con- accumulating over the past 15 years (DiClemente & Pro-
trolled. Self-liberation is when an individual believes in chaska, 1998). Assessment of the stage of change that a
him or herself and his or her ability to change. person is in is one of the most relevant findings for practice.
An integration of these processes with the stages can be Previous research on estimating stage distribution has
seen in Figure 1. In other words, there is a match between found that typically 40% of a population with an unhealthy
the stage that the patient is in and the intervention that is behavior would be categorized in the precontemplation
used. Individuals in the contemplation stage would be most stage, 40% would fall in the contemplation stage, and
open to consciousness raising, the use of dramatic relief, 20% would self-assess in the preparation stage (Dijkstra,
and an environmental reevaluation. In the action phase, DeVries, & Bakker, 1996; Fava, Velicer, & Prochaska,
effective use of the behavioral processes is particularly 1995). Several studies have focused on creating assessment
tools to determine the level of motivation for change which
include the 12-item Readiness to Change measure (Roll-
nick, Heather, Gold, & Hall, 1992), the 20-item Alcohol
Abstinence Self-Efficacy Scale (DiClemente, Carbonari,
Montgomery, & Hughes, 1993), the University of Rhode
Island Change Assessment (URICA) (McConnaughy,
DiClemente, Prochaska, & Velicer, 1989), the Stages of
Change Readiness and Treatment Eagerness Scale (SOC-
RATES) (Miller & Tonigan, 1996), and the Readiness Ruler
(D’Nofrio, Bernstein, & Rollnick, 1996).
Action oriented interventions often target the 20% of
the individuals in the preparation stage while the remaining
needs of the entire population are not being met. It would
Figure 1. Stages of change in which processes are most empha- therefore be incumbent to develop programs and interven-
sized. Reprinted with permission from Prochaska, Redding, & tions that either match the needs of individuals who have
Evers, 1997. not yet made the conscious effort to change or for health
 Shinitzky and Kub: Motivating Behavior Change 181

care providers to assist in moving those at-risk individuals TABLE 1. The Five General Principles of Motivational
along the continuum from precontemplation to action. Pro- Interviewing (Miller, 1983)
chaska and Velicer (1997) found that stage-matched pro- 1. Express empathy
grams can assist 80 to 90% of an at-risk population of a. Acceptance and understanding facilitates change
smokers. These authors also found that 40% of the individ- b. Skillful reflective listening is fundamental
uals who prematurely terminated treatment were initially c. Ambivalence is normal
assessed as falling into the precontemplation stage. 2. Develop discrepancies
Another important finding is that extensive relapse and a. Awareness of consequences is important
recycling occurs in populations attempting to take action b. Engage in a discussion between present behavior and
to change behavior. This appears to be the norm and has valued goals
important implications for practice. Terms such as ‘‘non- c. Client driven rational for change
compliant’’ and ‘‘unmotivated’’ are frequent labels applied 3. Avoid argumentation
a. Arguments are counterproductive
to patients who do not follow through on their treatment
b. Judging (why?) breeds defensiveness
plans. This may reflect the norm of relapse or may also c. Resistance is a signal to change therapeutic strategies
reflect a poorly created treatment plan that does not con- d. Labeling is unnecessary
sider the stage of change the patient is in. In labeling 4. Roll with resistance
patients as such, the provider may be externalizing respon- a. New perceptions are invited but not imposed
sibility, placing blame rather than reflecting upon his or b. Client is a valuable resource re: solutions
her own skills. Therefore appreciating the stage of change c. Collaboration is valued
the patient is in is imperative before we can begin to d. Mutually negotiated solutions
develop an optimal treatment plan. Assessing the patient’s 5. Support self-efficacy
position facilitates the development of an individually tai- a. Hope is motivating
lored and matched protocol. b. Patient is responsible for choosing and initiating
c. There is hope in the range of alternatives
Though our review of the Transtheoretical Model of
d. Knowledge that certain behaviors lead to desired outcomes
Change has focused on its application to an individual e. Possession of those behavior
patient, in actuality we may apply the model to families,
populations, and organizations. Prior to implementing an
intervention, one must assess and determine the readiness
to change. After determining the stage of readiness for that input by both parties. A starting point is to establish a safe
group or individual, the intervention may be tailored to environment in which our patients and their families feel
match their position. By doing so, we can increase the as though they can reveal personal information.
impact and effectiveness of our intervention. The art of motivational interviewing is therefore a dance
between two individuals suspending judgment and avoiding
a confrontational style thereby minimizing defensive reac-
MOTIVATIONAL INTERVIEWING
tions by the patient. Providers need to challenge patients
Once a patient’s stage of change is identified, the health without eliciting defensiveness. When a patient reacts defen-
care practitioner needs to implement clinical skills that sively, many providers tend to negatively label the patient
will help facilitate the patient’s progression and movement and accuse him or her of being noncompliant and resistant.
along the continuum. Motivational interviewing is a frame- We view this as a logical behavioral reaction on the part
work developed by Miller and Rollnick (1991) that can of the patient who may not perceive the issues in the same
help to facilitate this movement. It builds on the foundation manner. Providers need to be cautioned then, about challeng-
of understanding that our role as the health care provider ing a patient too early and creating a dynamic relationship
is to assist our patients to move toward a state of action that requires a defensive posture. As all behaviors are pur-
that leads to improved health status outcomes. A mutually poseful, we must understand what it is that our patient values
agreed upon treatment plan that is acceptable to the patient by maintaining his or her current unhealthy lifestyle behav-
and fits within the medical parameters is more likely to ior (for example, smoking).
be attained. Motivational interviewing is comprised of two Acceptance of the person does not mean agreement with
equally important phases, which include: Phase I— his or her behavior, but rather an appreciation of his or
building a therapeutic rapport and commitment, and Phase her perceived issues. We need to be more open to and
II—facilitating the movement through decisional analysis understanding of our patients’ life contexts. It is best to
and behavior change. Table 1 outlines the principles of start out with the patient’s agenda. No patient comes to us
motivational interviewing. without some emotional concern. The emotional concern
Motivational interviewing is a process that is based on is frequently the motivating factor that prompted him or
182 Public Health Nursing Volume 18 Number 3 May/June 2001

her to schedule an appointment and seek out an expert’s TABLE 2. Common Problems That Providers Display
opinion. A competent provider acknowledges the emo-
1. Asking closed-ended questions. These do not foster an open
tional components of the encounter. To avoid addressing dialogue between the patient and the provider. They usually
these issues is a sign that the provider’s agenda is control- limit the discussion to a yes or a no response.
ling the encounter. 2. Double options. Providers frequently assert an either-or
Another important role of the provider is to help our scenario. This implies that there are only two options and that
patients see that they are in control of their lives. The sense the provider is the one who knows which options are best.
of an internal locus of control, self-efficacy, and personal This style does not empower the patient to take an active role
empowerment leads to taking a more active role in one’s in problem solving.
life (Egan, 1998). The patient is ultimately the one respon- 3. Not responding to the emotional needs of a patient. Many
sible for making behavioral changes in his or her life. providers feel comfortable focusing on the bio-medical needs.
When mutually discussing treatment options and alterna- If a therapeutic rapport is not established, however, the patient
is likely to remain focused on their underlying emotional
tives, it is important to brainstorm. During the brainstorm-
issues that interfere with the effective flow of information
ing phase, ‘‘cast the net’’ as wide as possible. Subsequent and negotiation.
to identifying the vast array of possibilities, we then narrow 4. Using clichés to respond to patient disclosures. If used too
our options to the most viable alternatives. A key concept often, they are perceived as trite and minimizing to the
during the brainstorming phase is to suspend judging the patients.
best therapeutic fit. Criticizing forestalls creativity and
identification of all possibilities. Patients moving along the
continuum of change, need their providers to amplify the He presents with an upper respiratory infection (that is,
discrepancy between the pros and cons which make up wheezing, cough, and expectorant for 4 weeks). He has
their decision-making equation. During the encounter it is smoked for 25 years. He is 5’ 8,’’ 185 pounds, and has an
important to refrain from lecturing, for pontificating the unremarkable medical history. He has a positive family
‘‘right way’’ only alienates our patients. history for lung cancer in father and paternal grandfather.
As providers we need to weigh our words wisely. Every He requested some prescribed antibiotics to resolve his
question asked needs to have some underlying purpose. infection.
We need to be reflective of our style and of the line of
questioning. Whenever possible, providers need to avoid Nurse M: Mr. Smith, from what you have told me about your
habitually asking the question, why? (Benjamin, 1987). symptoms, what do think might have contributed to your
This connotes disapproval and forces the patient to respond infection?
with excuses or alibis. Asking open-ended questions is a Rationale: Respecting and valuing the patient as the
technique that encourages the patient to elaborate while expert in his own life is an important skill. This question
habitually using closed-ended questions leads to brief re- is posed as an open-ended question, which allows the pa-
sponses (that is, Yes or No). By utilizing these techniques tient to elaborate from his perspective. This question also
and skills, the encounter can be more rewarding. Recall that assesses the level of knowledge and insight the patient
each session must address the needs, concerns, and opinions has regarding his current condition as well as initiates an
of the patient. Lastly, emotional factors are dealt with and evaluation of his location regarding potential behavioral
problem solving is mutually managed. Common problems changes.
that providers can encounter are seen in Table 2.
Mr. S: I really don’t know. I just need an order for some meds.

CASE SCENARIO Rationale: Patient appears to be unaware or potentially

resistant and therefore, Precontemplative.
The following case scenario depicts a patient in the differ-
ent phases of the Transtheoretical Model of Change. Differ- Nurse M: Based on the length of time of your symptoms, I
believe that your smoking cigarettes adds to your condition. You
ent motivational interviewing approaches, some less
should stop smoking.
effective and colleagues more effective, are presented to
illustrate the value of applying appropriately matched tech- Rationale: The provider has made a summarizing com-
niques to help patients progress towards change. It is your ment, however, this comment is latent with judgment and
task to determine the stage of change that this patient confrontation. In essence, the provider is attempting to
currently fits and assess the encounter. The case scenario force the patient from precontemplation into the action
that we present is based on a synthesis of actual patient stage. This provider was talking at, rather than with the
encounters. patient. The statement of ‘‘obviously’’ is filled with
Mr. Smith is a 46-year-old, African American male. judgment. The provider asserts the ‘‘Gold Standards,’’ yet
 Shinitzky and Kub: Motivating Behavior Change 183

does not engage this patient in the problem-solving Mr. S: Well, you know, I guess there wouldn’t be any harm in
opportunities. that.

Mr. S: No, I don’t think so. I have been smoking cigarettes for Rationale: By not directly challenging, the patient is
several decades and I have never had this before. more accepting along the continuum. The patient is willing
to be reflective and accept educational information. We see
Rationale: The patient responds with resistance to the
the movement from precontemplation to contemplation.
confrontation. Denial is not a symptom of the addiction,
To further illustrate the movement along the continuum,
rather it is a defensive response to the provider’s accusation.
we shall continue with this patient encounter. Once a patient
From the responses of this patient (that is, lack of in-
is in the contemplative stage, our goal is to assist his
sight or awareness of behavior problem and resistance)
or her positive, healthy progression towards behavioral
we can determine that he falls within the category,
change.
precontemplation.
Encounter Analysis: If this provider dictates the medical Nurse M: Mr. S, from what you have told me about your symp-
treatment requirements without understanding and appreci- toms, what do you think might have contributed to your infection?
ating his or her patient’s life context, the patient will likely
Rationale: Asking an open-ended question facilitates
fail and be labeled as noncompliant. Now that the provider
the encounter. This question elicits the patient’s opinions.
knows that once you have determined the correct stage of
Again, we present this in a respectful manner that values
change, however, the goal is to facilitate movement to the
the patient’s observations and is therefore inclusive for
next stage (Precontemplative to Contemplative). This is
solutions.
best accomplished by matching motivational interviewing
techniques. Let us continue with Mr. Smith. Mr. S: Well, we have talked about how my smoking may be
making my infection worse and maybe even affecting my general
Nurse M: Mr. Smith, from the symptoms that you have expressed health.
and your history, I wonder if your smoking adds to this condition?
You might want to think about the potential impact of smoking Rationale: The patient used the word ‘‘we,’’ indicating
cigarettes has on your overall health. a mutual discussion rather than lecture from the provider.
Rationale: Again, using the history that the patient has Additionally, the patient states the possible connection be-
provided, active listening, and summarizing key points tween this behavior and adverse consequences. This indi-
back to the patient, the nurse displays genuine interest in vidual appears to be in the contemplation stage.
what has been said. This response also displays an active Nurse M: You’ve smoked for a couple of decades, what do you
listening style and the use of an indirect question. This find that you get from smoking?
free-floating style continues the assessment of motivation
and insight into the patient’s condition. By offering numer- Rationale: Since all behavior is purposeful, we need
ous suggestions without any declarative accusations, the to understand the reinforcing factors associated with this
provider is using the process of consciousness raising. behavior in order to adequately address this patient’s needs.
This is helping the patient to do a self-reevaluation.
Mr. S: I never gave much thought to that. I know my family and
home has been affected by cigarette smoking and perhaps I have Mr. S: I smoke when I am with my friends and it helps me to
too. relax.

Rationale: Patient is willing to consider this as a point Rationale: The patient openly discusses the rewards for
of reflection due to the nonjudgmental style of the provider. his current unhealthy behavior. These are needed when
The patient also reveals a potential consequence associated seeking leverage and when increasing the discrepancy be-
with the at-risk behaviors. Therefore, this patient has tween the pros and cons.
shifted to the contemplation stage. The nurse has helped Nurse M: I see. And what are the drawbacks?
the patient to use the processes of environmental reevalua-
tion and self-liberation. Rationale: Determining the patient’s level of insight
and now assessing the negatives that will facilitate the
Nurse M: Would you care if I provided you with some information
decision-making process.
for you to look over?
Mr. S: Well, we both know that it’s not doing me any good
Rationale: Here the provider is establishing a partner-
healthwise and it costs a lot.
ship with this patient. Based on what he has said before,
we know that he had not considered this as contributing Rationale: Mr. S is able to discuss both sides of the
to the problem. Engaging in option development without equation. He openly discusses the negative consequences
imposing a judgment is vital. associated with the at-risk behaviors. Again, these shall be
184 Public Health Nursing Volume 18 Number 3 May/June 2001

used to accentuate the discrepancy between reinforcing potential contributing behavior, we then pose an indirect
agents and contraindicators from the patient’s point of view. question. We have moved this patient further along the
continuum through empathetic listening, enhancing the dis-
Nurse M: It sounds like there are a few reasons that keep you
smoking and a few on the downside. There is a lot of evidence
crepancies, nonjudgmental problem solving, and empow-
that indicates cigarette smoking contributes to upper respiratory ering the patient. This free-floating style continues the
problems and knowing your family history places you at further assessment of motivation and insight into his condition.
risk for problems. If you were to see yourself in 6 months, what The provider refrained from labeling or presenting this
would you be doing differently and how would you go about in an accusatory manner. The provider is now using the
getting there? behavioral processes in the Transtheoretical Model of
Change. In particular, reinforcement management is being
Rationale: This provider paraphrases the relevant his-
used with the helping relationship.
tory using the patient’s words. An indicator of the contem-
plation stage is the motivation to change behavior over the
next 6 months. SUMMARY
Mr. S: Well, I have tried to quit in the past. I guess I could try This scenario provides us with examples of a patient in
to cut back. I would hopefully feel better than I do now. different stages of the change process. This scenario also
Rationale: This patient affirms his willingness to prob- provides us with examples of motivational interviewing
lem solve by altering his at-risk behavior. This patient is techniques that can be used to help our patient’s progress
expressing the emotional struggle associated with changing through each stage. Therapeutic movement is one stage at
behaviors. Knowing that 50% of all medical treatment a time. Assessing the patient’s readiness to change is the
plans are not followed through to their fullest extent, this first task for the provider. Once we have determined where
provider expresses an appreciation for the patient’s identi- our patients are along the continuum, our task is to facilitate
fied issue and attempts to partner with the patient to develop movement from their current position to the next stage.
a mutually agreed option. An individually tailored, matched service is recommended.
The health care encounter consists of two parties, in
Nurse M: That certainly sounds reasonable. Why don’t you give which both play a significant role in the dynamic process.
that a try. What do you think you could change over the next A provider who chooses not to utilize communication skills
month? that have been shown to improve the visit and the clinical
Rationale: Empathy and support. Rather than focusing outcomes is doing a disservice to his or her patient. We
on the negatives, this provider has chosen to begin by have the capabilities to positively affect the medical visit
establishing a therapeutic rapport through reinforcing a and to influence health. Using specific communication
positive. The provider is determining if this patient is in skills that enlist the patient’s active involvement in the
the preparation stage by inquiring if the behavior change encounter, developing the discrepancies between the pros
will occur within 1 month. and the cons of change, and mutually negotiating viable
options can shift a patient further toward adaptive healthy
Mr. S: I can think about what we have talked about and start behavior. Health promotion has been defined as the ‘‘sci-
making a game plan for changing my behavior. I guess I could ence and art of helping people change their lifestyle to
have fewer cigarettes. move toward a state of optimal health’’ (O’Donnell, 1987,
Rationale: This patient has progressed to the preparation p. 4). The integration of Prochaska and DiClemente’s
stage by displaying motivation and a plan to alter his Transtheoretical Model of Change and Miller and Roll-
behavior within the coming month. nick’s Motivational Interviewing techniques seamlessly
merge together to create an optimal patient encounter.
Nurse M: Is there anything I can do to help you reach this goal? This article has discussed the importance of using a
Rationale: Always survey for more information or con- model of change and motivational interviewing to improve
cerns. This displays your level of commitment and involve- health. Health promotion into the 21st century demands
ment and prevents those dreaded, ‘‘Oh, by the way’’ an approach that improves the ability of individuals to take
comments as you and your patient are leaving the office. action. Taking action involves at least two of the levels of
action outlined in the Ottawa Charter (WHO, Health and
Mr. S: Well besides standing next to me every moment, can you Welfare Canada, and the Canadian Public Health Associa-
tell me about some of those new treatment programs that I have
tion, 1986). It includes creating supportive environments
heard about?
where clinicians take into consideration the life context of
Rationale: This response displays an active listening their patients. In addition, it involves the development of
style to the patient. As this patient has already declared a personal skills to promote health. The Jakarta Fourth Inter-
 Shinitzky and Kub: Motivating Behavior Change 185

national Conference on Health Promotion has stressed that of patient compliance with therapeutic regimens. In D. L.
one priority is that of empowering individuals (WHO, Sackett & R. B. Haynes, (Eds.), Compliance with therapeutic
1997). This entails reliable access to the decision-making regimens. Baltimore, MD: Johns Hopkins University Press.
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