INSPIRING CH A NGE
Motivational interviewing for patients with
mood disorders
By Nancy Tylus-Earl, MA, MSN, RN-BC, and Jennifer Jones, MSN, PHN, PMHNP-BC
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EXCELLENT COMMUNICATION
is key, no matter where nursing care
is provided. From the ICU to the OR
to an inpatient mental health unit,
nurses must be flexible communica-
tors to promote positive change in
their patients.
The primary tool used in mental
health nursing is therapeutic
communication. Just as medical
technology is constantly improving,
so is the way that we communicate
to promote the best outcomes for our
patients. Research indicates that
motivational interviewing (MI) is an
effective communication style
when used to encourage behavior
change.1
In this article, we present a
project that explored the effect of
MI techniques applied by staff to en-
gage patients in recovery in an adult
inpatient mental health unit. Our
desired outcomes were increased
patient attendance at two cognitive
behavioral therapy groups and im-
proved quiz scores measuring staff
knowledge of MI techniques. After
the nursing staff on our unit were
taught basic MI skills and encour-
aged to use the techniques when
communicating with patients, both
outcome measures improved signifi-
cantly. Learning MI techniques en-
abled staff to use an evidence-based
communication style to encourage
patients to engage in recovery. This
article presents the steps taken to
achieve our project goals.
Setting the scene
Historically, the relationship
between the mental healthcare
18 l Nursing2018 l Volume 48, Number 2
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
professional and the patient has
been one of unequal power, which
included the professional giving
unsolicited advice.2 Today the
“doctor [or nurse] knows best”
philosophy is outdated, and a
collaborative relationship between
the patient and healthcare team is
recognized as the best practice for
promoting recovery.3,4
This project took place at a
149-bed mental health hospital in
California, on East Wing II (EWII), a
32-bed unlocked inpatient unit for
adults with mood disorders, thought
disorders, and chemical dependency.
Cognitive behavioral therapy
groups are offered on EWII each
day to empower patients to identify,
address, and manage thoughts and
behaviors that affect their mental
health. Patient participation in these
groups is crucial to improve mental
health outcomes.1
This quality improvement project
began when nursing staff expressed
dissatisfaction with a perceived inabil-
ity to engage patients in recovery.
Specifically, staff members felt unable
to persuade patients to participate in
cognitive behavioral therapy groups.
Patients must be empowered to
engage in decision-making as part of
the recovery process. This long
overdue shift in the way that we
communicate poses implementation
challenges for both the nursing staff
and patients. The desire of the EWII
unit staff to learn skills to encourage
patient engagement in recovery
prompted the formulation of an
action plan, starting with a literature
review.
Review of literature
MI is a patient-centered, evidence-
based method of facilitating change
to promote patient autonomy and
improve treatment concordance,
satisfaction, and clinical outcomes.1
Important components of MI
include expressing empathy and
encouraging patients to identify
discrepancies between their current
behaviors and long-term goals.5
Resistance is to be expected
when patients need to change
their maladaptive behaviors.1 MI’s
philosophy is to accept and “roll
with” resistance rather than to argue
with the patient, which doesn’t
promote positive change.6
MI isn’t just for psychiatric
nurses; it’s been effective in promot-
ing lifestyle changes such as weight
reduction and smoking cessation.1
MI has also been effective in
encouraging patients to adhere to
complex medical treatments such as
heart failure self-management.1
MI is effective in brief interven-
tions, with as few as two sessions
needed to sustain positive outcomes
for 2 years or more.7 Patients are
usually on our unit for less than
1 week, so using a tool that can be
used briefly to promote and sustain
optimal outcomes was important.
A study by Dray and colleagues
indicates patient satisfaction
increases when staff members use
MI techniques.8 This study deter-
mined that after staff members were
trained in MI, patients reported
feeling better able to approach and
communicate with the healthcare
team.8
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 MI is a cost-effective method of
empowering patients to change
problem behaviors.4 Train the trainer
and self-study are two of the least
costly training methods.9 Staff
training costs are only a minor
component of total treatment costs,
and only three to four staff feedback
or coaching sessions are needed to
sustain skills.8-10
Methods
During a brief morning huddle with
the unit clinical lead, EWII day-shift
staff members discussed their
frustration with limited patient
participation in group therapy. The
discussion evolved over several days,
and concluded with EWII staff
members requesting training in MI
techniques to ensure supportive,
change-oriented conversations with
patients.
Data collection began to de-
termine baseline patient group
attendance and staff knowledge of
MI techniques. On average, only
42% of patients were attending
cognitive therapy groups during
the preceding 2 months. This
confirmed the staff’s suspicion
that many patients weren’t attend-
ing groups.
An EWII staff member developed
the baseline quiz to measure staff
knowledge of MI techniques. The
seven-question multiple-choice quiz
was derived from two systematic
literature reviews on MI training.11,12
The average baseline score was 74%.
The quiz results demonstrated that
some staff members were inclined
to make unwanted suggestions to
patients; other responses revealed
the belief that patients can’t be
helped until they decide they
want help.
Before MI education, staff
members typically communicated
with patients in a therapeutic
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Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
manner. However, some staff
members attempted to engage
patients in a paternalistic way that
could be interpreted as conde-
scending. This communication style
isn’t in line with MI principles and
can be counterproductive when the
goal is to facilitate change.2 A
formal structured educational
approach was indicated to define
expectations and ensure compe-
tence among staff.
This project used the OARS
framework to teach MI. Conversa-
tions using the OARS technique
incorporate open-ended questions,
affirmations, reflective listening,
Motivational interviewing
is a cost-effective
method of empowering
patients to change
problem behaviors.
and summarization.2 The aim is
to engage the patient to work
through ambivalence about negative
behaviors or lifestyle changes.13
Staff members were asked how
they would like to receive MI
training to facilitate ownership of
the project. The unit practice council
adopted the project as a goal for the
year and provided feedback about
the educational design. Based on
staff input and preferences, several
teaching strategies were used,
including train-the-trainer, an MI
educational packet, one-on-one
discussion, and a video.14
The day-shift clinical lead
educated the evening- and night-
shift clinical leads and advanced
clinicians, who then educated their
nursing staff on their shift. Each
month, different MI techniques
were discussed and then role-
played in shift report and daily
huddle. Corresponding education-
al posters were displayed on the
unit.
The education implementation
phase of this project was somewhat
time-consuming and labor-intensive.
In part, this was because staff
education preferences were hon-
ored, but the one-to-one education
ensured time for questions, discus-
sion, and clarification as well as
role-playing when necessary.
Results
After receiving the MI training,
staff members’ average test score
improved from 74% to 89%. The
nursing staff used increased
knowledge of MI techniques to
communicate therapeutically with
patients to engage them in their
recovery. Staff members used OARS
techniques when interacting with
patients during shift assessments
and throughout the day. The clinical
leads and advanced clinicians
observed staff members and
provided feedback to assure
alliance with MI principles. After
staff incorporated MI into assess-
ments with the patients, patient
group attendance improved by
83%. (See Group attendance.)
During informal interviews, staff
members reported satisfaction with
the noticeable increase in patient
group attendance. Staff also reported
they noticed a culture shift, result-
ing in a changed relationship with
patients, from one of unequal power
to one promoting patient autonomy.
This partnership with patients
promoted engagement in recovery.
Instead of the nurse communicating,
“If you want to get better, then go to
group,” the nurse initiated a conver-
sation about the patient’s ambiva-
lence to change. This conversation
promoted a therapeutic alliance
February l Nursing2018 l 19
INSPIRING CH A NGE
Group attendance
80%
70%
60%
50%
51.8
40%
42.32
30%
20%
10%
0%
May June
N=319 N=222
This graph shows the percentage of patients attending cognitive behavioral
therapy groups. Staff implemented motivational interviewing techniques in July.
Group attendance increased 83% from May to September.
leading to patient empowerment to
participate in his or her recovery by
attending groups.
Discussion
Staff members were encouraged to
identify how they’d like to receive
training on MI techniques. Because
staff members were involved in
decision making, they felt owner-
ship of the project, which increased
participation. The various MI
training techniques, while time
consuming, enabled staff members
to ask questions about the training
and have one-on-one support. The
effectiveness of the training was
apparent in improved scores on the
MI knowledge quiz.
As observed by clinical leads and
advanced clinicians, staff members
used MI techniques consistently
when communicating with patients
to express empathy and to encour-
age identification of discrepancies
between problem behavior and
values. Staff knew to expect patients
to resist change and to accept this
resistance to support patient
autonomy.
Communication using MI
techniques led to increased group
attendance. The results of this
20 l Nursing2018 l Volume 48, Number 2
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
76.52 77.5
73.53
July August September
N=102 N=115 N=80
project align with current re-
search about the effectiveness of
MI to facilitate positive change and
treatment concordance by enhanc-
ing patient motivation.4
Recommendations
Our quality improvement project
provides an example of successful
collaboration between the formal
and informal leadership team on
EWII and the psychology depart-
ment. Many times, when the
frontline staff identifies a problem,
management steps in to solve it. The
situation described in this article
illustrates what can be accom-
plished when staff, management,
and a key ancillary department
engage in true collaboration and
teamwork.
Based on the results of this
project, we conclude that educating
staff on MI techniques can increase
patients’ participation in their
recovery, and our recommendation
is to train all staff throughout the
hospital. As part of the hospital
journey toward achievement of
Magnet® designation, MI will be
strongly emphasized in the future
and facility-wide training is
planned. ■
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In San Diego, Calif., Nancy Tylus-Earl is clinical lead at
Sharp Healthcare and adjunct faculty at the University
of San Diego and at Azusa Pacific University. Jennifer
Jones, formerly a clinical nurse at Sharp, is now in the
postgraduate psychiatric mental health NP residency
program at the San Francisco VA Health Care System.
The authors have disclosed no financial relationships
related to this article.
DOI-10.1097/01.NURSE.0000527613.60279.62
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