Open-ended questions. Typically, these questions start with “who,” “what,” “when,” “where,” and (with careful application) “why.” “Why” questions can seem judgmental, invite defensiveness, and, in most instances, should be avoided. An alternative to asking “why” is to insert the phrase, “Tell me about…” to nonjudgmentally encourage disclosure. Instead of asking “Why did you start using opiates excessively,” say, “Tell me about your experience with opiates.” If a “why” question is used, consider asking “Why did that feel important to you?” instead of the less effective “Why did you do that?”
Affirmation. When talking with the patient, listen for and remember examples of good decision-making, health management, and behavior change that you can affirm later. Consider, for example, a patient who’s having trouble remembering when to take his medications. When he tells you that his daughter has made a list of his medications and the correct times to take them in a large, easy-to-read font, you can affirm this by saying, “That is a great way to help visually remind you when to take your medications. I agree with your idea of taping that list on a kitchen cabinet, close to where you keep your medications to help you remember when to take them.”
Reflective listening. Every conversation has times to question and times to listen. Listening is frequently the most difficult part of MI to implement, so use your nursing skills to listen carefully and intuitively. Intuition helps you pull out the most important parts of a conversation that often go unsaid but, once said, add significant meaning and understanding. For example, when a nurse was speaking with a patient about possible neglect in a skilled nursing facility, the patient abruptly asked the nurse to leave and come back another day. The nurse’s initial response was to follow the patient’s request, but her intuition told her there was more to the situation. She said she would come back the next day and then added: “You have something to tell me tomorrow.” The patient eagerly responded, “Yes, I absolutely want to talk with you tomorrow.” The follow-up investigation revealed deficiencies in quality of care for this patient.
Reflective listening can be as simple as turning a question into a statement. For example, “You’re feeling hopeless” rather than, “Are you feeling hopeless?” This strategy allows you to check in with the patient in a nonthreatening way to uncover deeper meaning and to encourage healthy self-awareness—a critical first step in the process of changing health behaviors.
In more advanced applications of reflective listening, you can reframe and summarize what the patient has said; however, don’t simply repeat it. For instance, a patient on hospice refused to take the morphine prescribed to address her nocturnal dyspnea. The patient told the visiting nurse about a recent emergency department visit where she was diagnosed with a transient ischemic attack. She said that during the experience she felt light-headed and her thinking became fuzzy. The nurse reframed and summarized what she heard the patient say: “It sounds like that was frightening and that your body’s response to the morphine may be similar to what you experienced in the emergency department.” Summarizing and reframing affirmed the patient’s experience and allowed the nurse to provide education about the benefits of morphine to manage the nocturnal dyspnea.
Summarize and teach-back. Summarize any strengths the patient has shared, as well as action steps that have been discussed. To ease into summarizing, say something like “Tell me about your plans” or ask, “What else will you do?” Build on the expectation that the patient can focus on, remember, and follow through with the plan. Summarizing also helps identify and address gaps in knowledge and serves as a reminder of follow-up responsibilities.
Also consider asking the patient to teach back what he or she is going to do. The teach-back method promotes healthcare literacy by reinforcing key learning concepts and providing an opportunity to correct any misunderstandings. To help counter concerns that the patient may become defensive when being asked to repeat information, make it about you. For example, you can say, “To make sure I’ve done my job of explaining this to you, please show me what you’re going to do when changing this dressing.”
As with any new skill, practice and seek feedback from other nurses or team members so you can improve your proficiency and build confidence. As you become more competent at asking open-ended questions, affirming your patients, actively and reflectively listening, and summarizing patients’ plan of action, you’re engaging with them respectfully and compassionately.
MI’s future
Based on experience and literature reviews, the time is ripe for more MI nursing research. We need to know if MI impacts the delivery of patient-centered and compassionate care and if it contributes to patients’ healthcare literacy. We also need to learn if patient satisfaction increases when MI techniques are used and if nursing students experience less stress and engage more effectively with patients when using MI.
But you don’t have to wait for more research before putting the positive effects of MI into action. Begin by placing a focus on integrating MI into your daily nursing routine, as you support and encourage nursing research that will answer questions important to patients and nurses.
Debbie Bershad is a nursing professional development consultant at 360 HealthPartners in Novato, California.
Selected references
