Motivational Interviewing

Maria Karalis
Karen Wiesen

Assessing when patients are most amenable to listening and/or receiving information regarding their diets (or any other information related to their treatment) can lead to increased adherence. Saran et al. (2003) found that in patients on hemodialysis non-adherence to medical information is an ongoing challenge that is associated with increased mortality and hospitalization risk. Assessing when patients are most amenable to listening and/or receiving information regarding their diet or any other information related to their treatments can lead to increased adherence. As clinicians, we each need to objectively assess our approach to counseling – not just our style, but when we attempt to provide information, and whether or not it is conducive to effectively modifying patient behavior. If we counsel and educate at the most opportune times, we can increase patient understanding and adherence.

The Stages of Change

The stages of behavior change should be taken into account before any education takes place. In the case of the renal diet, resistance to change occurs because we often prescribe the diet that patients should follow and then try to persuade them to change. We are often too “task-oriented” and may disregard the patients and their willingness or unwillingness to change.

According to Miller and Rollnick (1992), the five stages of change are also known as the “Transtheoretical Model of Change.” These stages of change help us understand how people change behavior with the individual’s readiness to change as the focus. They include:

1. Pre-contemplation – the patient is unaware, unwilling or discouraged regarding the need to change.
2. Contemplation – the patient is actively considering a change.
3. Preparation – the patient has full intentions on changing in the very near term.
4. Action – the patient is taking action to create change.
5. Maintenance – the stage where the change needs to be sustained and the focus should be on lifestyle     modifications to avoid a setback.
6. Relapse – the stage where a setback occurs (this can happen at any time).

Healthcare providers have a role at every stage of this continuum. Our role should be to empower patients and serve as a coach by motivating them and rewarding even the smallest changes. Table 1 provides motivational phrases and statements to facilitate behavior change in every stage. Patients often progress and regress through the stages. As such, we should always re-assess the patient’s readiness to change, as the previous assessment may no longer be valid.

The purpose of assessing where the patient is on this continuum of change is to provide motivation, information, and confirmation at the right times in order to facilitate and accelerate change. Signs that a patient is ready to make a change may include decreased resistance and an increased discussion about the issue. The patient may begin to ask more questions and begin to envision or “contemplate” the change. The patient may begin talking about the advantages of or intention to change. According to Koster, Verheijden, and Baartmans (2005), this is our cue to action.

Motivational Interviewing and the Power of Communication

Miller and Rollnick (1992) define motivational interviewing as a psychological approach that aims to increase motivation to engage in treatment or a direct, client-centered counseling style for eliciting behavior change by helping patients to explore and resolve ambivalence. This approach is more focused and goal-directed.
The way we communicate with our patients can impact how successful they are in adapting to their overall treatment plan. There are four main activities that can positively influence the interaction between the patient and clinician.

• Ask non-judgmental, open-ended questions. This can help build trust in the relationship by showing the patient that you are sincerely interested in their viewpoints, values, and interests. Talk less than your patient does – this gives you plenty of information on how well they understand and you can then clear up any misconceptions if needed.
• Listen carefully. We are often mentally preparing to talk next and not really listening to the patient. Make it a habit to rephrase what the patient has just said. This tells the patient that you understand what you heard them say. Sometimes we think we understand but until we check for understanding, we cannot be confident that we fully understand the concerns of the patient. Watch for those nonverbal cues or “body language.” This will give you an idea of the patient’s intention to adhere to the proposed change.
• Set goals with the patient and not for the patient. The patient and family members, as appropriate, should actively participate in determining short and long-term, realistic, goals. We need to create an atmosphere in which patients feel that their views are valued and respected. If patients are involved in setting their own goals from the beginning, they will feel part of the process and will have an increased understanding of the rationale for doing so. This will lead to increased adherence.
• Involve the patient in problem solving. As adults, we are better able to remember instructions if we are involved in identifying obstacles and seeking realistic solutions.

The Clinician as a “Partner”

After assessing what stage the patient is in, the clinician should then guide the patient and serve as a partner or coach, by providing motivation and the tools the patient needs to be successful. The following strategies will empower patients.

1. Take the time to build a relationship with the patient before providing any information.
2. Within professional boundaries, get to know the patient as a person. This will help build trust. If a patient doesn’t trust you, they won’t listen to you.
3. Find out what motivates the patient. Be sure to use open-ended questions.
4. Maintain a positive attitude even during times of confrontation and setbacks.
5. Celebrate all successes and give sincere compliments. This helps to maintain motivation.
6. Involve the patient in setting realistic goals and problem solving. The patient understands the barriers better that you.
7. Talk less and listen more.
8. Check for understanding and paraphrase often.

Motivating patients should not be a daunting task. Here are 10 ways to motivate patients from the patient’s perspective (some ways have been modified in the spirit of motivational interviewing) as presented at a Renal Support Network Patients Educating Patients & Professionals (PEPP) Presentation, entitled “Promoting Patient Participation in the Dialysis Setting” by Virna Elly (2006):

1. Provide a vision of the future.
2. Add some fun and variety to the patient’s routine.
3. Engage the patient in providing input to the healthcare plan.
4. Accentuate the positive aspects of patient’s health.
5. Appreciate the patient’s efforts.
6. Assist in developing goals and challenges with the patient, not for the patient.
7. Develop measurements to illustrate improvement.
8. Promote social interaction among patients.
9. Ask questions and then listen to the patient’s feedback.
10. Provide lots of encouragement.

As clinicians, we have the responsibility to provide useful information in understandable terms. This may involve different teaching methods depending on the patients’ learning preferences. Once this is accomplished and we have checked for patient understanding, it is then the responsibility of the patient to adhere to the recommendations. Not all patients will follow our advice, even if they understand the rationale and know what they need to do. That is their choice. However, it is our responsibility to ensure we have provided patients with the tools they need in a way that is most conducive to modifying their behavior.

References
Elly, V. (2006, May). Promoting patient participation in the dialysis setting. In Renal Support Network, Patients educating patients & professionals (PEPP) program. Presented at the 4th Annual New Jersey CRN Renal Nutrition Conference, Princeton, NJ.

Koster, F.R.T., Verheijden, M.W., & Baartmans, J.A. (2005). The power of communication. Modifying behaviour: Effectively influencing nutrition patterns of patients. European Journal of Clinical Nutrition, Suppl 1, S17-S22, 59.

Miller, W.R., & Rollnick, S. (2002). Motivational interviewing: Preparing people for change (2nd ed.). New York: Guilford Press.

Saran, R., Bragg-Gresham, J.L., Rayner, H.C., Goodkin, D.A., Keen, M.L., Van Dijk, P.C., et al. (2003). Nonadherence in hemodialysis: Associations with mortality, hospitalization, and practice patterns in the DOPPS. Kidney International, 254-262, 64.

Additional Resource
Miller, W.R. & Rollnick, S. (1995) What is MI? Behavioural and Cognitive Psychotherapy, 23, 325-334. Retrieved February 19, 2007, fromhttp://motivationalinterview.org/clinical/whatismi.html.