CARDI OVASCULAR INTERVENTI ONS

Motivational interviewing: a useful approach to improving

cardiovascular health?
David R Thompson, Sek Y Chair, Sally W Chan, Felicity Astin, Patricia M Davidson and Chantal F Ski
Aim. To review and synthesise, systematically, the research ndings regarding motivational interviewing and to inform edu-
cation, research and practice in relation to cardiovascular health.
Background. Motivational interviewing is designed to engage ambivalent or resistant clients in the process of health behaviour
change, and it has been widely used in different clinical conditions such as substance abuse, dietary adherence and smoking
cessation. Motivational interviewing has also been proposed as a method for improving modiable coronary heart disease risk
factors of patients.
Design. Systematic review.
Method. Eligible studies published in 19992009 were identied from the following databases: CINAHL, Medline, PsycINFO,
Cochrane Library, EBSCO, Web of Science, Embase and British Nursing Index. A manual search was conducted of bibliog-
raphies of the identied studies and relevant journals. Two researchers independently reviewed the studies.
Results. Four meta-analyses, one systematic review and three literature reviews of motivational interviewing and ve primary
studies of motivational interviewing pertaining to cardiovascular health were identied. Despite a dearth of primary studies in
cardiovascular health settings, there appears to be strong evidence that motivational interviewing is an effective approach
focusing on eliciting the persons intrinsic motivation for change of behaviour.
Conclusion. Motivational interviewing is an effective approach to changing behaviour. It offers promise in improving car-
diovascular health status.
Relevance to clinical practice. This review indicates that motivational interviewing is a useful method to help nurses improve
health behaviour in people with coronary risk factors.
Key words: coronary heart disease, health behaviour change, motivational interviewing
Accepted for publication: 17 August 2010
Introduction
Cardiovascular disease is largely attributable to adverse
health behaviours, such as smoking and physical inactivity.
A major challenge facing nurses in improving cardiovascular
health is working with individuals to change behaviours
that are potentially harmful to health. Many of these
behaviours are deeply entrenched in an individuals lifestyle,
and attempts to accomplish these changes are often difcult
and require considerable time and effort. Of signicance,
many individuals are ambivalent in wanting to change these
behaviours as they are commonly pleasurable or the
Authors: David R Thompson, PhD, MBA, RN, FRCN, FAAN, FESC,
Professor of Nursing, Cardiovascular Research Centre, Australian
Catholic University, Melbourne, Victoria, Australia; Sek Ying Chair,
PhD, RN, Associate Professor, Nethersole School of Nursing,
Chinese University of Hong Kong, Shatin, Hong Kong; Sally W
Chan, PhD, RN, Professor and Director of Education, Alice Lee
Centre for Nursing Studies, National University of Singapore,
Singapore; Felicity Astin, PhD, RN, Senior Research Fellow, School
of Healthcare, University of Leeds, Leeds, UK; Patricia M Davidson,
PhD, MEd, RN, Professor of Cardiovascular and Chronic Care,
Curtin Health Innovation Research Institute, Curtin University,
Sydney, New South Wales; Chantal F Ski, PhD, MAPS, Associate
Professor, Cardiovascular Research Centre, Australian Catholic
University, Melbourne, Victoria, Australia
Correspondence: David R Thompson, Professor, Cardiovascular
Research Centre, Australian Catholic University, 4/486 Albert Street,
Melbourne, Victoria 3002, Australia. Telephone: +613 9953 3680.
E-mail: David.Thompson@acu.edu.au
1236 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 12361244
doi: 10.1111/j.1365-2702.2010.03558.x
individual doubts their ability to change (Rollnick et al.
1992).
Mere advice-giving is unlikely to be successful, but there
are available methods applicable to any behaviour, such as
smoking, physical inactivity and over-eating, which can be
used in health promotion, risk reduction and prevention of
chronic conditions such as coronary heart disease (CHD)
(Rollnick et al. 2000). Such methods rely on partnership
between clients and health professionals and are designed to
satisfy the need for brevity imposed by the realities of
contemporary health care as well as opportunistic interven-
tions and the problems of resistance and lack of motivation.
Although behaviour change can often occur spontaneously
and some patients can respond to brief advice (ve to
10 minutes), this is not always the case. Some patients may
require more intensive behaviour change counselling (15
20 minutes) and others a specialist method such as motiva-
tional interviewing, which has its roots in the addictions eld
(Miller 1983). Establishing rapport, setting agendas and
assessing importance and condence (and readiness) to
change are integral to this approach (Rollnick et al. 2000).
This paper aims at giving a brief overview of motivational
interviewing and evaluating studies that used this technique
in cardiovascular health settings.
Motivational interviewing
Motivational interviewing (Rollnick & Miller 1995, Miller &
Rollnick 2002) has been dened as a client-centred, directive
method for enhancing intrinsic motivation to change by
exploring and resolving ambivalence (Miller & Rollnick
2002, p. 25). It is not founded on theory but has evolved from
the client-centred counselling approach of Rogers (1951). It is
a method of communication rather than a set of techniques
and its focus is on eliciting the persons intrinsic motivation
for change. Concepts such as reective listening are balanced
with a directive approach. The spirit (Miller & Rollnick
2002, p. 35) of motivational interviewing includes collabora-
tion (as opposed to confrontation), evocation (as opposed to
education) and autonomy (as opposed to authority).
Four broad guiding principles underlie motivational inter-
viewing (Miller & Rollnick 2002):
1 Express empathy (acceptance facilitates change; skilful
reective listening is fundamental; ambivalence is normal).
2 Develop discrepancy (client rather than counsellor should
present the arguments for change; change is motivated by a
perceived discrepancy between present behaviour and
important personal goals or values).
3 Roll with resistance (avoid arguing for change; resistance
is not directly opposed; new perspectives are invited but
not imposed; client is primary resource in nding answers
and solutions; resistance is a signal to respond differ-
ently).
4 Support self-efcacy (persons belief in the possibility of
change is an important motivator; client, not counsellor, is
responsible for choosing and carrying out change; coun-
sellors own belief in persons ability to change becomes a
self-fullling prophecy).
Motivational interviewing consists of two phases. During
the rst phase, intrinsic motivation for change is enhanced,
whereas in the second phase, commitment to change is
strengthened (Miller & Rollnick 2002). It is a dynamic and
interactive process where there is reciprocity between the
individual and counsellor.
Motivational interviewing is an empirically supported,
theoretically consistent and rapidly diffusing approach to
health behaviour change (Antiss 2009). There is a growing
body of literature pertaining to the use of motivational
interviewing in health settings in general (Britt et al. 2004), as
well as in specic conditions and areas such as substance
abuse (Noonan & Moyers 1997), dietary adherence (Berg-
Smith et al. 1999), pregnancy (Tappin et al. 2005) and
diabetes (Greaves et al. 2008). Commonly, patients with
cardiovascular disease face the need to change multiple
behaviours; therefore, identifying the behaviour that is most
important to the client to change is a useful strategy. The aim
of this review was to review and synthesise systematically the
research ndings regarding motivational interviewing so as to
inform education, research and practice in relation to
cardiovascular health.
Method
Inclusion criteria
Types of studies
This review included secondary studies (meta-analyses, sys-
tematic reviews and literature reviews) of motivational
interviewing. It also included primary studies that examined
the effect of motivational interviewing on cardiovascular risk
factors. With a paucity of randomised controlled trials
(RCTs), other research designs such as quasi-experimental,
cohort and casecontrol and pre- and post-test studies were
considered for inclusion.
Types of participants
The secondary studies inthis reviewincludedadults (aged>18
years). The primary studies included adults (aged >18 years)
with at least one, or more, newly diagnosed or existing car-
diovascular risk factors.
Cardiovascular interventions Motivational interviewing in cardiovascular health
2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 12361244 1237
Type of intervention
This review targeted the intervention of motivational inter-
viewing delineated akin to engaging ambivalent or resistant
clients in the process of guiding to elicit and strengthen
motivation for health behaviour change.
Outcome measures
The outcomes that were considered for inclusion were major
cardiovascular risk factors:
Obesity
Smoking
Treatment non-compliance
Physical inactivity
High alcohol consumption/abuse
Diabetes
Hypertension
Poor diet/nutrition
High blood pressure
High blood cholesterol.
The identied outcomes were evaluated in a variety of
ways, for example questionnaires on lifestyle changes,
smoking and exercise behaviour, assessment instruments on
nutrition and audits of medical records.
Search strategy
The search strategy aimed at nding published literature
sources in the English language for the period January 1999
December 2009. Before starting the search, the search terms
and key words were reviewed by a librarian.
Key search terms for the literature included the following:
Motivational interviewing
Cardiovascular risk factors
Cardiovascular
Heart disease
Health outcomes.
In the second step, all identied keywords were used for
searching the databases listed below.
Databases for published literature searched included the
following:
CINAHL
Medline
PsycINFO
Cochrane Library
EBSCO
Web of Science
Embase
British Nursing Index.
A manual search was conducted of bibliographies of the
identied studies and relevant journals. The electronic search
and journal exploration resulted in 26 papers that seemed to
be relevant for the review. Based on the information given in
the title and abstract, these papers were assessed against the
inclusion criteria by two reviewers. The reference lists of the
retrieved articles were assessed for inclusion based on their
title, but no new articles were identied. Finally, eight
secondary source papers and ve primary source papers were
left for appraisal, and full-text articles were retrieved.
Quality assessment
Identied studies that met the inclusion criteria were grouped
into one of the following categories as dened by the
National Heart, Lung and Blood Institute categories for
levels of evidence (Table 1). Each paper was assessed by two
independent reviewers for methodological quality prior to
inclusion in the review using an appropriate critical appraisal
instrument. Disagreements between the two reviewers about
Table 1 National Heart, Lung, and Blood Institute (NHLBI) categories for levels of evidence
NHLBI
category Sources of evidence Denition
A Randomised controlled trials (RCTs).
Extensive body of data
Evidence is from endpoints of well-designed RCTs that provide a consistent pattern
of ndings in the population for which the recommendation is made. Category A
requires substantial numbers of studies involving substantial number of participants.
B RCTs. Limited body of data Evidence is from endpoints of intervention studies that include only a limited number
of patients, post hoc or subgroup analysis of RCTs or meta-analysis of RCTs. In
general, category B pertains when few randomised trials exist, they are small in size,
they were undertaken in a population that differs from the target population of the
recommendation or the results are somewhat inconsistent.
C Non-randomised trials, observational
studies
Evidence is from outcomes of uncontrolled or non-randomised trials or from
observational studies.
D Panel consensus, judgement The panel consensus is based on clinical experience or knowledge that does not meet
the above criteria.
DR Thompson et al.
1238 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 12361244
whether to include a particular research paper were resolved
by a third reviewer. Owing to the paucity of RCTs, the
majority of the research papers meeting the inclusion criteria
were level C. Papers meeting the inclusion criteria were
assessed with the use of a validity checklist.
Data extraction
The rst author abstracted the data and included character-
istics of the studies including participant demographics,
intervention descriptions, cardiovascular risk factors, out-
comes and additional notes including the results. All deci-
sions on inclusion and allocation of the outcomes measures
were based on a consensus by all authors. Whenever
necessary, unpublished or missing data were requested by a
second or third reviewer.
Data synthesis
For the main reason that studies were clinically diverse with
outcomes that were insufciently homogeneous, a meta-
analysis of the included studies was not undertaken. A
narrative analysis of the key ndings from primary and
secondary studies was therefore provided. Synthesis and
aggregation of ndings and conclusions made in relation to
the intervention were amalgamated to shape a credible
accurate conclusion of the research studies and to identify
the area of need of further research.
Results
Studies of motivational interviewing
The results from primary studies are generally mixed,
whereas those from secondary studies (systematic reviews
and meta-analyses) are generally positive. A systematic
review of 29 randomised trials of motivational interviewing
in the areas of substance abuse, smoking, HIV risk behav-
iours and diet and exercise (Dunn et al. 2001) found that it
was an effective substance abuse intervention method when
used by clinicians who are non-specialists in substance abuse
treatment. Sparse and inconsistent ndings revealed little
about the mechanism by which motivational interviewing
works or for whom it works best. Sparse data regarding
intervention delity and high rates of attrition make it
challenging to interpret these studies.
A meta-analysis of 30 controlled clinical trials of adapta-
tions of motivational interviewing in the areas of alcohol
abuse, smoking cessation, drug addiction, HIV risk behav-
iours, treatment adherence and diet and exercise (Burke et al.
2003) found them be as effective as other treatments and
more effective than no-treatment or placebo controls, in the
areas of alcohol, drugs and diet and exercise, but reported
contradictory evidence in the areas of smoking cessation and
HIV risk behaviours. A later and extended meta-analytic and
qualitative enquiry of 39 studies examined the effectiveness
of adaptations of motivational interviewing in the same areas
but with the addition of treatment compliance, eating
disorders, asthma management and injury-risk behaviours
(Burke et al. 2004) found them to be as effective as other
general interventions and yielded moderate effect sizes in
areas such as substance abuse and diet and exercise. The issue
here with these two reviews is the denition of adaptations.
It is not clear from either review what is meant by
adaptations and to what extent they occur, and this
necessarily casts doubts on the veracity of whether it is really
motivational interviewing, particularly in the absence of
reporting intervention delity.
A meta-analysis of 72 clinical trials of the effectiveness of
motivational interviewing in the areas of alcohol, smoking,
HIV/AIDS, drug abuse, treatment compliance, gambling,
intimate relationships, water purication/safety, eating dis-
orders and diet and exercise (Hettema et al. 2005) found
small to medium effects in improving health outcomes.
Similarly, a meta-analysis of 72 randomised controlled
studies in the areas of smoking cessation, diabetes, asthma,
weight loss and physical activity, alcohol abuse and addiction
(Rubak et al. 2005) found a signicant effect of motivational
interviewing in 74% of the studies reviewed (though this
increased to 81% among motivational interviewing sessions
lasting one hour). The authors suggested that the likelihood
of an effect was positively correlated with the number of
encounters and with a prolonged follow-up period. They
concluded that motivational interviewing outperforms tradi-
tional advice-giving. However, methods of tailoring the
timing and dosing of interventions may augment the
potential of the intervention to leverage behaviour change.
A systematic review of motivational interviewing in phys-
ical health care settings (Knight et al. 2006) found eight
studies in the elds of diabetes, asthma, hypertension,
hyperlipidaemia and heart disease. The majority of these
studies found positive results for the effects of motivational
interviewing on psychological, physiological and lifestyle
change outcomes. However, some of the studies reported the
use of motivational interviewing in conjunction with other
interventions, such as skill-based counselling and health
education, thereby making delineation of the inuence of
motivational interviewing impossible.
A review of ve studies using motivational interviewing
to control paediatric weight, diet and physical activity and
Cardiovascular interventions Motivational interviewing in cardiovascular health
2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 12361244 1239
others to control diabetes and smoking (Resnicow et al.
2006) suggests that although its use might be feasible with
children and adolescents, more studies with youths are
needed in these areas to determine the clinical utility of
motivational in the prevention or treatment of child
obesity.
Another review of ten studies examining the effectiveness
of motivational interviewing for weight loss and exercise
(Van Dorsten 2007) found that it signicantly improved both
as well as diet and regimen adherence. However, Van
Dorsten makes the important point that meta-analysis of
specic motivational interviewing effects has proven difcult
given that many adaptations of motivational interviewing
have been used in empirical studies.
An up-to-date review of 37 studies of motivational
interviewing for diet and exercise, diabetes and oral health
suggests that it is effective in all these areas, although
additional research is needed in the oral health arena
(Martins & McNeil 2009).
Although these reviews attest to the benets of motiva-
tional interviewing, problems identied by most of them
included the following: small sample sizes, lack of statistical
power, use of disparate multiple outcomes, inadequate
validation of measures, poorly described interventions, min-
imal description of intervention delity and training (Knight
et al. 2006). Many studies reporting the outcome of motiva-
tional interviewing do not provide adequate information on
what the intervention involved or how it may have been
modied for a particular problem or population, thus making
it difcult to draw conclusions and make comparisons (Britt
et al. 2004). There is a pressing need to understand and
specify how motivational interviewing exerts its effects
(Hettema et al. 2005) and for studies to examine the long-
term effects of motivational interviewing (Martins & McNeil
2009), including cost-effectiveness (Resnicow et al. 2006).
The ndings to date suggest that this model of intervention
has signicant potential and with rening may be an
important strategy in changing behaviours. To date, the
majority of the studies conducted and reviewed and which
provide the greatest support for motivational interviewing
address addictive behaviours, particularly problem drinkers
(Britt et al. 2004) and comparatively few address behaviour
change among the chronically ill (Konkle-Parker 2001,
Mesters 2009).
Use of motivational interviewing in cardiovascular health
settings
Rather surprisingly, in view of the growing body of evidence
attesting to its effectiveness, there is a comparative dearth of
research examining the effectiveness of motivational inter-
viewing in cardiovascular health (Hancock et al. 2005).
Table 2 gives an overview of empirical studies using
motivational interviewing in clients at risk of or with
established CHD or heart failure. Of these six studies, one
reported the use of motivational interviewing alone in
outpatient cardiac rehabilitation (Everett et al. 2008), one to
improve heart failure self-care (Riegel et al. 2006), one to
promote physical activity (Brodie & Inoue 2005) and
enhance quality of life for people with chronic heart failure
(Brodie et al. 2008), one in a hospital dietetic department to
provide dietary advice for people with hyperlipidaemia
(Mhurchu et al. 1998) and one in a primary health care
setting for counselling patients at risk of CHD (Hardcastle
et al. 2008) but using a modied motivational interviewing
approach. Hancock et al. (2005), in their review of research
evaluating motivational interviewing, reported that many
studies used small samples (2261 patients) and those with
large samples did not show a signicant difference between
groups. They reported evidence of effect in controlling
substance abuse but a lack of information on the quality of
the technique.
To gain insights into a nurse-delivered motivational
interviewing intervention in the outpatient cardiac rehabil-
itation setting, Everett et al. (2008), as part of an RCT of
104 patients, assigned the intervention group to participate
in two one-hour sessions with a nurse trained in the
technique of motivational interviewing. The technique was
well received, and the authors concluded that it has
signicant promise in the cardiac rehabilitation setting. In
two studies by Brodie and Inoue (2005) and Brodie et al.
(2008), eight one-hour home-based sessions of motivational
interviewing were compared to and combined with standard
care in 60 older patients with heart failure. Results showed
improvements in reported physical activity (Brodie & Inoue
2005) and in health-related quality of life in the treatment
group (Brodie et al. 2008).
Riegel et al. (2006) used a motivational approach designed
to improve self-care in 15 patients with heart failure. A mixed
method, pre-test post-test design, was used to evaluate the
proportion of patients in whomthe intervention was benecial
and the mechanism of effectiveness. Patients received home
visits from a nurse trained in motivational interviewing and
family counselling. The researchers reported improved self-
care in 714% of the patients receiving the intervention.
However, some caution is warranted because their
success might be because the patients were aware they
had a chronic condition, and their comments indicate a
desire to improve their symptoms. There was only one
nurse involved in the intervention who was given thorough
DR Thompson et al.
1240 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 12361244
training. The patients therefore had greater continuity,
and the nurse had the opportunity to become more
procient.
Determining adherence to the spirit and technique of
motivational interviewing can be performed using tools such
as the Motivational Interviewing Skills Code and Motiva-
tional Interviewing Treatment Integrity. These tools are
important to use to not only demonstrate intervention delity
or adherence with the motivational interviewing technique
but also as a reective tool for the practitioner. The absence
of reporting of intervention delity makes it difcult to
interpret ndings.
Table 2 Summary of empirical studies using motivational interviewing in clients at risk of or with established CHD
Authors, population,
and setting
Study aim, design,
intervention and concurrent
treatment Fidelity measures
Follow-up and
attrition Outcome
Brodie and Inoue (2005)
Older adults (60+) with
HF (n = 60)
UK hospital wards
Promote physical activity
RCT (three groups)
Three groups: MI (22);
standard care (18); MI and
standard care (20)
Eight times per hour sessions
No concurrent treatment
reported
None reported 5 months (35%) All three groups showed a
signicant increase in
distance, but there was no
difference between groups
Brodie et al. (2008)
Same sample as above
(data collected 2002)
Assess whether MI improves
quality of life
Used SF-12, MLHFQ and
Motivation and Readiness
for Physical Activity Scale
As above
As above As above MI group showed a signicant
increase in three domains of
SF-12 compared to standard
care group
Hardcastle et al. (2008)
Adults (1865) at risk of
developing CHD
(n = 218)
UK primary care
Determine whether multiple
patient-centred lifestyle
counselling sessions of
interest to patients at risk of
CHD
RCT
Two groups: counselling/
AMI (125); control (93)
Up to ve 2030 minutes
sessions
Exercise and nutrition leaet
Review of audiotapes
and monthly
consultation meetings
6 months (35%) AMI group showed a
signicant decrease in BMI
and increase in physical
activity levels compared to
control group. Both groups
reported a signicant increase
in fruit and vegetable
consumption and a reduction
in dietary fat
Mhurchu et al. (1998)
Adults with
hyperlipidaemia
(n = 97)
UK hospital clinic
Promote reduction of fat
intake
RCT
Two groups: MI (47);
standard care (50)
Three times sessions (mean
1 hour 42 minutes)
No concurrent treatment
reported
Used a coding system to
determine if were
different
3 months (20%) No difference between groups;
both showed reductions in
total and saturated fat
Riegel et al. (2006)
Adults with HF (n = 15)
US home visits
Improve HF self-care using
MI
Mixed methods with pre-test,
post-test design and
qualitative component
Each participant received
three (15) visits from a
specialist nurse over
3 months
None reported? used
core elements of MI
3 months Self-care improved
MI, motivational interviewing; AMI, adapted motivational interviewing; HF, heart failure; CHD, coronary heart disease; RCT, randomised
controlled trial.
Cardiovascular interventions Motivational interviewing in cardiovascular health
2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 12361244 1241
Discussion
The evidence indicates that motivational interviewing is a
useful approach to behaviour change. It is superior to
traditional advice, improves with increased intensity
(number and length of encounters) and appears effective
even with brief encounters. In addition, it has greater
congruence with trends to ensure patient-centred care and
to engage and involve individuals in self-management. But,
implementation into routine clinical practice needs to be
demonstrated (Rubak et al. 2005, Mesters 2009). Finally,
there is a need for appropriate training and evaluation. As
pointed out by Mesters (2009), training in motivational
interviewing is often delivered through a single workshop,
and whether this amount of training is sufcient to make a
difference in clients responses is not clear. Although it
appears that developing the attitude and knowledge neces-
sary may not be too time-consuming, the skills required for
effective motivational interviewing may take longer to develop
(Britt et al. 2004). There is also the danger that in a mutual
participation model, where patients are assigned more respon-
sibility, the responsibility of the health professional is abro-
gated and more intensive strategies are precluded.
There is great appeal in motivational interviewing being a
practical front-line approach that is consistent with the call
for more patient-centred approaches in health care where the
health practitioner and patient relationship is seen as a
partnership (Emmons & Rollnick 2001, Antiss 2009).
However, there are some gaps in the evidence base that need
to be addressed before it can be applied with condence in
routine practice.
For instance, motivational interviewing does not speci-
cally ask patients about their misconceptions or understand-
ing of the risk of their health behaviour, and these are
important considerations that may inhibit a successful
outcome. The urgency to change some behaviours associated
with an acute cardiac event, for example, may require more
didactic and emphatic approaches.
Supporting self-efcacy is a central principle of the
motivational interviewing approach, with the latter attempt-
ing to increase the patients belief in his or her ability to
change his or her behaviour. But this concept is often poorly
understood and applied, and there is a need to develop a
precise understanding of the effectiveness of specic rather
than general self-efcacy to support patients appropriately in
their self-management (Lau-Walker & Thompson 2009).
The use of a motivational interviewing approach in high-
volume and fast-paced health care environments, such as
cardiovascular clinics, is challenging. However, using this
technique particularly in opportunistic encounters may be of
use in leveraging behaviour change. Ensuring adequate
training, skill development and monitoring is important.
Finally, more research is needed to understand how
motivational interviewing exerts its effect and what elements
of motivational interviewing are essential. It is also unclear
which patients would benet most from motivational inter-
viewing and this is important in targeting individuals (Britt
et al. 2004). Further evaluation of motivational interviewing
should involve obtaining the views and perspectives of
participants. Pawson and Tilley (1997) advocate asking
clients whether they feel the intervention has achieved its
goals and if not why. Also, identifying the cultural appropri-
ateness of this method, particularly in cultures where a more
authoritative approach is expected, is important. Further, the
focus of the motivational interviewing approach is on the
individual, rather than the more collective focus in some
cultures.
Limitations
Limitations of motivational interviewing have been acknowl-
edged by Miller and Rollnick (2002). They conclude that
there is reasonable evidence that it works in certain applica-
tions but that the data are less clear regarding how and why it
works. They do not regard it as a panacea but as one method
that can be used in concert with others, and they acknowl-
edge that, in some contexts, it is appropriate to educate, offer
clear advice, teach skills, coerce or make decisions for
another. This is sage advice; commonly, strategies and
techniques are adopted with minimal critique. Identifying
individuals most likely to respond to this technique is critical
to adopt this in cardiovascular care. Many individuals at high
risk or with cardiovascular disease have multiple risk factors,
which poses a major challenge as most studies of motiva-
tional interviewing have targeted a single behaviour only.
Conclusion
The evidence thus far attests to motivational interviewing
being an attractive and effective means of changing behaviour
and the potential to offer great promise. Identifying the
niche for this technique in cardiovascular care is an important
focus for future research.
Relevance to clinical practice
Nurses can play a key role in improving modiable CHD
risk factors of patients. This review indicates that motiva-
tional interviewing is a useful method to help nurses
accomplish such health behaviour change, but there remain
DR Thompson et al.
1242 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 12361244
some gaps in the evidence base that need to be addressed
before it can be applied with condence in routine practice.
Ensuring adequate training, skill development and monitor-
ing is important.
Acknowledgements
The authors thank Dr Brent Van Dorsten, University of
Colorado Denver, USA, for helpful comments. This review
forms part of a study funded by the Health and Health
Services Research Fund, Hong Kong.
Contributions
Study design: DRT, FA, CFS; data collection and analysis:
DRT, FA, CFS and manuscript preparation: DRT, SYC,
SWC, FA, PMD, CFS.
Conict of interest
None.
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