Introduction

Motivational interviewing is a communication style characterized by its collaborative and goal-oriented approach to delving into underlying issues related to resistance or ambivalence toward behavior change.[1] Motivational interviewing strategies have been incorporated into various realms of healthcare, including medical care, dentistry, physical therapy, and numerous other disciplines.[2][3][4] This activity reveals the positive and beneficial effects of motivational interviewing in enhancing motivation for behavioral changes and improving medication adherence.[5][6]

Function

Considering the deeply personal nature of behavior change, motivational interviewing emerges as a valuable tool for facilitating positive behavioral shifts. This skill proves particularly beneficial when addressing behaviors that individuals may find challenging to alter, with frequent references to its application in the management of addiction, obesity, and other chronic diseases. However, the utility of motivational interviewing extends beyond these domains, demonstrating relevance across a spectrum of therapeutic and counseling.

Motivational interviewing is often used alongside the transtheoretical model, which provides a systematic framework to comprehend and address the process of behavioral change.[7] This model suggests that individuals progress through a series of stages toward behavior modification (see Table 1. Transtheoretical Model of Change). An accurate assessment and recognition of an individual's stage of change allows clinicians to encourage progression to the next stage or reinforce the maintenance of a changed behavior through motivational interviewing. This patient-centered therapeutic approach to communication involves gauging an individual's internal desire and willingness to make a positive change.[8] Through these reflections, pharmacists and other healthcare professionals can better understand and explore personal motivations and obstacles to change, facilitating targeted counseling, education, and the provision of other resources.[9]

Table 1. Transtheoretical Model of Change

Engaging in discussions about personal preferences, values, and belief systems necessitates establishing a trusting patient relationship. Motivational interviewing offers an empathetic framework for fostering trust and addressing ambivalence or resistance in a nonjudgmental manner using effective communication principles. Various techniques, such as reflective listening, open-ended questioning, and affirmation, contribute to creating a supportive environment that encourages understanding and meaningful discussion.

Overall, by establishing collaborative relationships, motivational interviewing allows practitioners to customize interventions according to each individual's distinct characteristics, values, and goals. This skill considers the readiness and willingness to change, providing a personalized approach to care that enhances the relevance and effectiveness of the intervention. 

Issues of Concern

Building Trusting Relationships

Motivational interviewing is commonly acknowledged for fostering comprehension and facilitating behavior change in individuals who may be hesitant, ambivalent, or resistant to change.[5] At its core, the spirit of motivational interviewing is defined by the cultivation of trusting, collaborative patient relationships, which necessitates the practice of accepting and empathizing with patient needs, beliefs, values, goals, readiness, experiences, and perspectives.[10] Motivational interviewing enables practitioners to explore and strengthen an individual's intrinsic motivation to make positive changes in their behavior. Such conversations may reveal discrepancies between an individual's current behavior and their values and goals, which can be crucial points of reflection in considering change.[5] Motivational interviewing provides a structured yet flexible framework that allows practitioners to engage patients in personalized discussions about change while steadfastly honoring the patient's autonomy in the decision-making process.[10]

Specific Techniques

Although motivational interviewing follows general principles, practitioners must adapt their communication strategies to suit each individual's specific needs, motivations, and circumstances. Considering the techniques used in motivational interviewing as a foundational guide rather than a rigid structure enables practitioners to customize their approach to fit the unique characteristics of their patients. 

Motivational interviewing skills are captured in the OARS acronym, which includes open-ended questions, affirmation of strengths, reflective listening, and summarization (see Table 2. Motivational Interviewing Skills). Open-ended questions foster conversations that encourage patients to share and elaborate on their experiences and perspectives, particularly regarding health beliefs and barriers to change. Reflective listening is essential for acknowledging the patient's shared experiences. Repeating or rephrasing information provided by the patient enables them to rectify any misunderstandings on the listener's part.[11]

The practitioner should avoid interrupting or correcting the patient as they share their personal values and beliefs to build a nonjudgmental relationship. While similar to reflective listening, summarization is a skill that involves acknowledging several key concepts throughout the discussion rather than focusing on a single statement. Lastly, affirmation of strengths refers to acknowledging positive patient characteristics or past achievements, potentially boosting confidence or readiness to contemplate behavior change.[12] 

 Table 2. Motivational Interviewing Skills

These skills are often associated with expressing empathy, which constitutes 1 of the 4 core principles of motivational interviewing (see Table 3. Motivational Interviewing Principles).[13] As practitioners delve deeper into understanding the patient, differences between the individual's values and behaviors may become apparent. By acknowledging this discrepancy, practitioners can assist patients in identifying it and determining whether action should be considered. For individuals who exhibit ambivalence or reluctance toward behavior change, using the technique of "rolling with resistance" is essential to honor patient autonomy.[14] Change talk using tools such as 10-point rulers to assess readiness, willingness, or confidence to change may be particularly beneficial in exploring reasons for ambivalence or reluctance. The fourth principle, supporting self-efficacy, incorporates the skill of affirming strengths and focuses on providing positive reinforcement as patients endeavor to change their behavior.

Table 3. Motivational Interviewing Principles

 Challenges

Several perceived barriers to motivational interviewing exist, including the time needed to incorporate the skills and principles in practice. However, it is noteworthy that the benefits of motivational interviewing are not contingent on a specific amount of time for effective delivery. Another barrier involves a lack of confidence through inadequate training and comprehension of motivational interviewing concepts, which can be addressed through training and educational programs.[15] In addition to challenges, common pitfalls associated with motivational interviewing exist (see Table 4. Common Pitfalls).[11]

Table 4. Common Pitfalls

Clinical Significance

As accessible and trusted healthcare professionals, pharmacists are critical in promoting health and wellness. Equipped with training in screening, prevention, and management of chronic conditions, pharmacists utilize motivational interviewing skills to offer comprehensive education and counseling covering both medications and lifestyle behavior modifications.[16] A primary focus lies in enhancing adherence, with challenges often arising in cases of time-consuming or complex regimens or those indicated for asymptomatic conditions.[17] 

Studies examining motivational interviewing as a patient-centered communication approach have suggested improved adherence rates for chronic conditions, including hypertension, diabetes, heart failure, and chronic pain, and improved acceptance rates for immunizations.[18][19][20][21][22] Furthermore, motivational interviewing has also been associated with benefits in encouraging and maintaining lifestyle changes, including physical activity.[23] As a result, motivational interviewing strengthens pharmacists' ability to engage in health promotion efforts. 

Other Issues

Health Literacy

Pharmacists and other healthcare professionals care for people from all different backgrounds, beliefs, and health literacy levels. The Centers for Disease Control and Prevention (CDC) divides health literacy into personal and organizational definitions. Personal health literacy refers to finding, understanding, and using information to make health-related decisions. In contrast, organizational health literacy refers to how organizations enable individuals to find, understand, and use information for health-related decisions (CDC. Health Literacy Basics). These definitions emphasize the use of health information and acknowledge how health literacy impacts others. Health literacy significantly impacts medication understanding, including missed prescription refills and inappropriate dosing or timing of medications.

As a result, individuals with low health literacy are at higher risk of outcomes, including increased rates of hospitalizations and greater use of emergency care. Health literacy disparities are prevalent among vulnerable populations, contributing to the perpetuation of health disparities. Clear communication without medical jargon promotes health equity, and addressing health literacy is fundamental to improving health outcomes within and across communities. Several tools have been developed to examine or assess literacy, health literacy, and numeracy (see Table 5. Health Literacy Screening Tools).[24][25][26][27][28][29][30]

Table 5. Health Literacy Screening Tools 

Certain factors such as age, education, and health insurance status may predispose individuals to low health literacy (NCES, National Assessment of Adult Literacy). Indications of low health literacy include frequently missed appointments, medication nonadherence, difficulty identifying medications or recalling their purpose and dosage, asking fewer questions, and failure to follow through on tests or referrals (AHRQ, The Agency for Healthcare Research and Quality. Health Literacy: Hidden Barriers and Practical Strategies). However, it is noteworthy that low health literacy cannot be discerned through appearances alone. As a result, universal precautions are recommended wherein care delivery should consider everyone to have limited health literacy. Successful implementation of motivational interviewing and effective communication involves several strategies to address varying levels of health literacy (see Table 6. Strategies for Addressing Health Literacy) (AHRQ. Health Literacy: Hidden Barriers and Practical Strategies).[31][32]

 Table 6. Strategies for Addressing Health Literacy

Documentation

Documenting patient interactions in the medical record is important for follow-up and communicating changes with the medical team. Documentation should be clear, concise, and comprehensive. To mitigate the risk of misinterpretation, clinicians should adhere to the US Institute of Safe Medication Practices (ISMP) list of error-prone abbreviations, symbols, and dose designations. This list contains symbols and abbreviations commonly associated with errors or mistakes, which can have harmful results.

Medical documentation should include patient concerns and health beliefs. For patients who decline changes due to ambivalence or reluctance, their reasons should be noted in a nonjudgmental manner. Documentation should also be completed in a timely manner, ideally as soon as the encounter has ended. To this end, templates for common encounters could be established in the electronic medical record for efficiency. However, caution should be exercised when cutting and pasting information from previous notes to minimize the risk of perpetuating outdated or inaccurate information. Indeed, some institutions prohibit providers from using cut-and-paste functions within patient encounter notes to mitigate these errors. 

Enhancing Healthcare Team Outcomes

Motivational interviewing is a communication strategy built upon collaborative relationships between the patient and practitioner. This strategy encourages using open-ended questions and reflective listening to foster a deeper understanding of patient experiences, perspectives, and beliefs. This understanding enables practitioners to tailor interventions to each patient's distinct characteristics, values, and goals.[10] The structured yet flexible framework allows practitioners to engage patients in meaningful conversation while keeping patient autonomy at the forefront of the decision-making process.[10]

All members of the healthcare team can incorporate motivational interviewing into patient interactions. For example, physicians and advanced practitioners can use reflective listening to identify patient perspectives and beliefs when determining disease management strategies. Pharmacists can ask open-ended questions to engage patients in understanding medications and medication adherence. Nurses can demonstrate empathy to build and strengthen patient relationships. In addition, office staff and other healthcare team members can also incorporate aspects of motivational interviewing where appropriate. 

Health systems and medical offices should incorporate training and support documents to educate team members on the successful implementation of motivational interviewing for every aspect of patient care. These training sessions should be conducted collaboratively with all healthcare team members to ensure each discipline comprehends how motivational interviewing can be integrated into their respective roles. Furthermore, motivational interviewing training should be incorporated into standard training programs for remote work and practitioners learning to interact with patients using web-based platforms.