Motivational Interviewing for Patients with Chronic Kidney Disease

Abstract

Successful management of chronic kidney disease (CKD) typically involves consideration of several lifestyle changes and treatments that could improve patients’ health outcomes. The complexity of behavioral changes and treatment decisions that must be made by patients, with the support of their treatment team, could diminish their motivation to address CKD and lead to poorer treatment outcomes. Hence, motivational enhancement, in the context of patient education and shared decision making with the treatment team, is a critical issue in CKD patient care. This article describes how motivational interviewing can be used with patients to enhance their motivation to address CKD and participate in treatment.

Patients diagnosed with chronic kidney disease (CKD) face multiple decisions regarding their healthcare and management of their disease in partnership with their interdisciplinary treatment team. These decisions involve consideration of several lifestyle changes and treatments that could improve their health outcomes. This article describes how motivational interviewing (MI) (1-2), a well-established evidence-based broad behavior change approach (3-5), can be used with patients to enhance their motivation to address CKD and participate in treatment.

Patient Motivation in the Treatment of CKD

There is increasing interest in the use of MI with patients with CKD. Successful management of CKD typically involves improving diet, increasing physical activity, quitting smoking, and controlling fluid intake, blood pressure, blood sugar, and phosphorus. In addition, patients consider a variety of treatment options (e.g., home versus clinic-based dialysis, choosing fistulae versus catheters for hemodialysis access) that they must adhere to for the treatments to work well. The complexity of behavioral changes and treatment decisions, combined with the fact that many patients have not yet begun to feel the effects of their illness, could diminish their motivation to address CKD and lead to poorer treatment outcomes. Hence, motivational enhancement, in the context of patient education and shared decision making with the treatment team, is a critical issue in CKD patient care.

What is Motivational Interviewing?

Miller and Rollnick (6, p. 29) define MI as “a collaborative, goal-oriented style of communication with particular attention to the language of change. It is designed to strengthen personal motivation for and commitment to a specific goal by eliciting and exploring the person’s own reasons for change within an atmosphere of acceptance and compassion.” Key to the style or spirit of interacting with patients in MI is a focus on working together with patients in a partnership, accepting the patients’ stance in treatment, compassionately promoting the patients’ welfare, and evoking from patients their strengths and resources that would help them change. Conversationally, the provider draws out the patients’ arguments that favor change (called “change talk”), while understanding and helping to resolve, as needed, arguments that sustain unhealthy behavior (called “sustain talk”), such that patients talk themselves into making changes.

Four overlapping processes comprise MI and are represented as stair steps, each building upon one another over the course of the interview (6). In this model, “each later process builds upon those that were laid down before and continue to run beneath it as a foundation” (p. 26). The processes include engaging (connecting with patients and establishing a good working relationship), focusing (agreeing on the target of motivational enhancement and directing the conversation toward it), evoking (drawing out the patients’ own motivations for changing the target behavior), and planning (developing commitment to change and formulating a specific plan of action). Providers move flexibly between these processes in response to the clinical situation and act like a guide rather than an expert during the transaction (2).

Two main MI skill sets are simultaneously in motion across the four overlapping processes. First, providers use core interviewing skills that build rapport, convey empathy, and clarify the goals toward which the patients and providers will move together. These skills include asking open questions to invite conversation about a topic, affirming positive aspects of the patient, reflecting what the patient has communicated, and summarizing periodically, often referred to as the OARS of MI. In addition, mapping out an agenda, often through the exchange of information between patients and providers, is another core skill used to set a target for motivational enhancement and provide direction in the interview.

Second, providers use specific strategies to elicit patients’ change talk. Change talk includes statements that prepare or build motivation for change, such as desire, ability, reasons, or need to make changes in health behaviors (DARN). Change talk also refers to statements that mobilize patients’ specific change efforts, such as expressions of commitment to change, activating language that details how change might occur, and taking preliminary steps toward change (CAT). Exchanging information, asking evocative questions, decisional balances, importance and confidence rulers, and developing change plans are commonly used strategies in MI.

Motivational Interviewing for CKD

Rollnick, Miller, and Butler (2) present a useful model for the application of MI in healthcare settings. They describe a simple process in guiding patients toward health behavior changes (see Figure 1). The provider must first engage the patient by establishing rapport, primarily through the use of the OARS delivered in the spirit of MI. Next, the provider and patient reach an agreement about the focus of the visit through agenda mapping, namely, the process in which they “map out” the different health behavior issues and choose a direction the patient wants to explore. Then, the provider works with the patient to enhance motivation for change by exchanging information, using evocative questions to elicit change talk, as well as more specific strategies like the use of decisional balance or importance and confidence ruler activities. Finally, the provider summarizes the discussion, asks a key question to determine the patient’s readiness to change and, as appropriate, plans with the patient what he or she will do to achieve his or her change goals. If the patient is not ready to change, the discussion will continue at the next appointment. Examples of these skills within each step of the model follow.

Figure 1.

A model for using Motivational Interviewing in healthcare settings.

Establishing Rapport

The provider begins each interaction by establishing (or reestablishing) rapport with the patient by identifying their role on the healthcare team, asking opening questions about the patient’s health status and concerns, affirming the patient, and reflecting the patient’s viewpoint.

Provider: Good morning Mr. Smith. My name is Carol and I am the nurse who is part of your treatment team. My understanding is that you’re here today to work with me to learn how to get better control of your blood sugar levels. What is your understanding of why we are meeting? (open question that fosters partnership)

Patient: Well, I’m pretty overwhelmed by my blood sugars. They’ve been all over the place and I don’t know where to start. I could really use some help. I find it hard to stick to the diet and I haven’t really started to exercise. Most of the time I take the medication, but honestly sometimes I forget.

Provider: So you’ve been trying to make some changes (affirmation that supports effort to change) and have found it difficult to take them on all at once. (reflection that shows acceptance)

Agenda Mapping

Agenda mapping is characterized by the provider and patient identifying the multiple options for discussion and then working together to select the most important topic, or behavior, to focus on for the visit.

Patient: Yeah, I really have been trying.

Provider: You sure have, and you are taking on many things at once (compassionate reflection). You mentioned your diet, exercise, and taking medications. It might help you feel less overwhelmed if we focus on just one of these today and see how you want to proceed. Which of these would you like to talk about today to help you get better control of your blood sugar? (collaborative open question to focus the discussion)

Patient: I guess I’m not taking my medicine, the Glyburide, every day like I should. Maybe we can start there.

Provider: Okay, let’s start there.

Enhance Motivation for Change

A reciprocal flow of information between the patient and provider, using an elicit-provide-elicit technique, increases the likelihood that the patient will openly consider the provider’s input about CKD and its treatment. Moreover, asking evocative questions, using a decisional balance strategy or importance and confidence rulers to elicit change talk are examples of other useful skills for enhancing patient motivation for change.

Elicit-Provide-Elicit

This strategy is used to exchange information with patients in a manner that respects the information they already know. Specifically, providers 1) elicit from patients what they know about the topic being discussed, 2) provide information as needed, and 3) elicit patients’ reactions to the shared information.

Provider: Tell me more about what you know about taking the Glyburide. (elicit information the patient may already have regarding insulin)

Patient: I know that I’m supposed to take it in the morning, and that’s about all I know right now. A few times when I’ve taken it, I’ve felt really light headed a little while later so I was worried that it was doing something bad to my sugars.

Provider: You are right about needing to take it in the morning and there are some other things I’d like to tell you about taking Glyburide, if that’s okay with you? (asking permission in order to maintain partnership while providing education)

Patient: Sure, go ahead.

Provider: Well, you are correct that you should take the Glyburide in the morning. It’s also very important that you take this medication 15 to 30 minutes before you eat because it can cause low blood sugar if taken without eating something. That might be why you sometimes feel light headed after taking the medication. If you take the Glyburide and then eat a light breakfast, you should be able to avoid the light headedness. (provide information and education) What do you think about that? (elicit patient’s understanding and thoughts about the information just provided)

Asking evocative questions

These open questions attempt to elicit patient change talk or ask patients to elaborate more about their stated motivations for change. Table 1 shows several examples arranged under the different DARN-CAT change talk categories.

Provider: Last time we met, we reviewed some recommended changes to your diet because your blood pressure was elevated. Your blood pressure is still on the high side. We had talked about reducing salt in your food. How did it go?

Patient: Not that well. I tried to cut back on salt, but I don’t like how things taste if they aren’t seasoned.

Provider: Even though you like the taste of salt, you still tried to reduce how much you use. How come? (evocative question)

Patient: I was worried about my health, and I want to see my granddaughter graduate medical school. You said my blood pressure was high and that it increased my risk for all kinds of problems, especially heart problems. Did you say my blood pressure is still high?

Table 1.

Examples of Evocative Questions within Change Talk Categories (DARN-CAT)

Desire	“How do you want your health to improve?”
Ability	“Of these different ways to improve your diet, which ones do you feel most able to try?”
Reasons	“What would be the advantages of being more physically active?”
Need	“How urgent does getting on dialysis seem to you?”
Commitment	“What part of what we discussed are you ready to do?”
Activation	“What steps are you willing to take between now and your next appointment?”
Taking Steps	“How have you already moved in this direction?”

Decisional balance

Use of a decisional balance activity (i.e., exploring the pros and cons of changing and not changing) is common in MI. This activity provides a structured method for understanding the basis of a patient’s ambivalence in that the benefits of change (“If I improve my diet, I’ll delay the need for dialysis for many years”) and the costs of not changing (“If I don’t change how I eat and exercise, a heart attack may kill me before my kidney disease does”) provide reasons to change, whereas the benefits of not changing (“A person has got to have some pleasure”) and the costs of changing (“Healthy food is expensive”) provide reasons to remain the same. By strategically eliciting more reasons for change and, to the extent possible, resolving reasons to remain the same (e.g., identify some healthy foods that taste good and are affordable), a provider might help the patient tip the balance toward change.

Provider: So you’re thinking about making some diet changes to help keep your fluids reasonable between dialysis visits. Tell me a little about reasons for keeping things the way they are with your diet.

Patient: Because its summer and I like to be outside a good bit, it gets really hot and I like keeping cool with ice water. I also really like to eat watermelon during the summer months too.

Provider: What’s making you feel like you need to control your fluids better?

Patient: Even though I love having a lot of ice water and watermelon, I know that if I go too far and get fluid overloaded, it could be serious. It’s not good for my heart, and I feel like putting that kind of pressure on my body probably isn’t worth it.

Provider: What other reasons can you think of to better control your fluids?

Importance & Confidence Rulers

Rulers are used in MI to assess a patient’s level of motivation and also to elicit change talk. A 0-10 ruler can be used to ask about various dimensions of behavior change, including the importance of making a change, the patient’s confidence in their ability to make a change, or their readiness (or willingness) to make a change. Asking the patient why he or she has given the provider a particular number (e.g., 5), as opposed to a lower number (e.g., 0), elicits change talk (e.g., reasons that make changing important or factors that support confidence) Asking the follow up the other way (Why did you give me a 5 and not an 8?) elicits defense of the status quo, and moves the discussion away from change.

Summarize and Ask Key Question

Another important skill is how to gauge patients’ readiness to change and to determine if it is appropriate to mobilize their motivation to change by initiating a change planning process. Providers typically recapitulate what the patient has said, especially those statements that suggest how they are now ready to change. Following this summary, providers then pose a key question to solidify commitment to change (“What’s your next step?” or “From what you’ve told me, how do you want to proceed?”). A helpful analogy is of a patient as a skier standing at the summit (assisted up the mountain by the provider)(6). The key question provides a supportive nudge that helps the person go down the mountain.

Planning for Change

Change planning is an overall strategy providers use to negotiate a plan with patients about how they will change their behavior. Critical to this process is maintaining a patient-centered stance in which the plan is derived by the patient, with the assistance of the provider, rather than the provider becoming prescriptive at this point. Providers ask patients to set their targeted behavior change goal (“I am going to monitor my blood sugar once a day”), describe steps they will take to change (“I will test it in the morning before I eat my breakfast”; “I will record my level each day on my monitoring form”), identify who might support them and how (“I am going to ask my wife to review my sugar levels at the end of each week”), anticipate obstacles (“I travel once in awhile and need a way to not forget to take my glucometer with me”), and reaffirm their commitment to the plan. If during the process of mobilizing their commitment, patients become uncertain again (the cold-feet phenomenon), the provider reflects this ambivalence rather than trying to press through it and provides another opportunity to revisit the plan in the current meeting or at another time. Being in a hurry to complete the plan when patients are not ready is a common trap into which providers fall.

Research about MI for CKD

Whereas MI was originally developed for use with patients with alcohol use disorders, it has been adapted successfully for use in healthcare settings. A growing body of literature has demonstrated that MI is highly effective in a variety of situations relevant to CKD, including managing diabetes (7), increasing physical activity (8), weight loss (9), and improving eating habits (10). In addition, several recent studies in the nephrology literature have shown that use of MI contributes to better fluid management (11), improved exercise adherence (12), better controlled phosphorous and albumin levels (13) and improved treatment adherence (13-14) and disease self-management (15).

Future Directions

More research is needed to better understand how MI can be used with maximal benefit in patients with CKD. For example, it will be useful to examine how best to package MI techniques to make them quickly absorbed and effectively implemented by CKD providers, as well as assuring that they are well-received by the patients they treat. Adapting MI techniques to make them function within fast-paced, interdisciplinary settings where CKD patients are treated is critical for its growth as an application in this population. Moreover, additional studies designed to examine which clinical outcomes are most susceptible to improvement through the application of MI is warranted. Ultimately, such research could determine if using MI to target specific clinical outcomes translates into improved CKD prognosis (e.g., slower progression to transplantation) as well as fewer or less severe comorbid diseases/complications (e.g., cardiovascular risk).