Motivational Interviewing (MI) to Change Type 2DM Self Care Behaviors: A Nursing Intervention

Abstract

Aims

This paper evaluates a novel nursing intervention designed to improve physical and psychological outcomes for adult patients with Type 2 DM.

Background

Self care behaviors are an important component of diabetes treatment, yet for many reasons, patients do not adhere to suggested plans. Motivational Interviewing (MI) is a patient centered strategy that helps overcome ambivalence to change. Nurses, who frequently educate patients with diabetes about self care, can use MI as a way to improve health behaviors.

Methods

As a component of a large RCT, focus groups were used to evaluate the impact of an MI nursing intervention. Nineteen patients (8% of treatment group) participated in four different groups. IPA was used to explore patient response to the intervention.

Results/Findings

Patients were able to reflect on and identify responses to sessions with the study nurses that differed from “typical” health care provider visits. Many of their descriptions captured the essence of MI practice.

Conclusion

MI is a viable and useful technique for nurses to use in educating and caring for persons with Type 2 DM.

Introduction

As with other chronic illnesses, self management behaviors are important for patients with Type 2 DM. Exercise, diet, medication adherence, monitoring, routine follow-up care, and other health promoting behaviors can prevent complications and enhance well-being. However, in one study of patients with diabetes, this regimen would require an extra two hours each day to carry out (Russell, Suh, Safford, 2005). In addition to time constraints, patients may not make life style changes because of financial or transportation problems, availability of or access to health care providers, and/or cultural belief systems (Saydah et al., 2007; Nwasuruba et al., 2008; Strauss et al., 2006; O'Connor et al., 1999).

Nonetheless, encouraging patients to engage in and take on beneficial behaviors is an important health care intervention. For example, even a 1% drop in HbA1c can lead to a 33% reduction in microvascular complications (Lancet, UKPDS Group, 1998). However, due to lack of time or communication skills, many health care providers (HCPs) fail to fully explore whether patients follow through on their recommendations, or to determine whether barriers to self management can be modified or not. Patients, however, report this is not the case (Abdulhadi et al., 2007).

Consequently, patient adherence rates are low, and in the U.S., mean HbA1c levels have not changed in the last decade--currently, only 7% of patients are at goal for A1c, LDL, and BP levels (Saaddine et al., 2002). In other countries, the statistics are similar: in the UK, 39.7% of patients had an HbA1c < 7.4% (Campbell, O'Roland, Middleton, & Reeves, 2005).

Background

With the incidence of diabetes increasing yearly, nurses in all specialty areas are likely to care for patients with this chronic disease, which can have serious co-morbidities. It has been estimated that by the year 2030, the global prevalence of diabetes will nearly double (Wild et al., 2004). Medical care for diabetes accounts for over $174 billion U.S. health care dollars per year because on average, expenses for a person with diabetes are six times those of a healthy person. Hypertension and hyperlipidemia, two common diabetic co-morbidities, can lead to increased mortality and further escalate the cost of care (ADA, 2008). Using the computerized generic formal disease model, (Roglic et al., 2005), the global mortality from diabetes in 2000 was 2.9 million (5.2% of all deaths).

In addition to physical complications, diabetes adversely affects emotional health and well-being. Clinical depression rates among those with diabetes are high and estimated to be between 10 & 30 % (Anderson et al., 2001, Li et al., 2008). Since cognitive function influences the ability to manage daily self-care, psychological difficulties can have an indirect but negative impact on glycemic control.

Experts in diabetes education say that the greatest challenge to improving outcomes for patients with Type 2DM is more effective multicomponent behavior change strategies (Norris et al., 2004). “Typical” approaches include scare tactics, advice-giving, badgering, and other highly directive styles which are not conducive to behavior change (Moran, Bekker, Latchford, 2008). In contrast, interventions that include patient empowerment, education, psychosocial understanding, and more recently, brief behavior change counseling have shown promising results.

Motivational Interviewing

Motivational Interviewing (MI) is a patient-centered counseling approach that actively engages patients and draws on their underlying motivation for change (Miller, 1983; Rollnick & Butler, 1999). Founded by psychologist William Miller and physician Steven Rollnick, MI specifically stresses the importance of understanding each patient's unique perspectives and priorities when developing a treatment plan, then uses reflective listening, therapeutic communication, and rapport-building skills to empower the patient to make behavior changes (Miller, 1983; Miller, & Rollnick, 1991).

The success of this strategy within the substance abuse field has prompted practitioners from various backgrounds to use it with other medical and psychological problems such as HIV, cardiac rehabilitation, and eating disorders. Results have ranged from slightly effective to significant.

Nurses and Behavior Change

Nurses have long been on the forefront of trying to help patients change behaviors which influence health. Konkle-Parker (2001) describes MI as a model that “allows the health care provider to support medication adherence in a client-centered fashion” (p. 61). In The Healthy Aging Project (HAP), Bennett and colleagues (2005) used a form of MI to have nurses coach older adults on healthy behavior. In comparison with their uncoached counterparts, after six months, the nurse-coached group had significantly less health distress. Brodie & Inoue (2004) conducted a study with 60 elderly patients where group one received a cardiovascular nurse specialist teach patients about exercise in conjunction with an MI interview, as compared to a second group with nurse teaching only, and a third with MI only. While all groups improved their exercise, those in the MI and the MI plus nurse groups increased the level and type of activities.

Another study of 402 patients on osteoporosis medication used nurses to provide counseling via telehealth, with improved results and better adherence than the general population (Cook, Emiliozzi, & McCabe, 2007). A feasibility study of use of MI in the cardiac rehabilitation setting offered promising results (Everett et al., 2008) and nurses regarded it as a favorable strategy for persons with substance abuse (Littlejohn & Holloway, 2008). Hamilton, O'Connell, and Cross (2004) explored how school nurses could use MI to help students stop smoking. Using principals of MI, the nurses developed a resource that thirteen nurses tried and found useful.

Aims

This study is part of a larger NIH-funded grant (R18-DKO67495) designed to translate empirical knowledge regarding diabetes treatment and management into a clinical intervention which improves patient outcomes. The grant is a five year RCT of adult patients with Type 2 DM from diverse primary care clinics throughout central Pennsylvania, a largely rural location with many medically underserved areas. The control group (n=247) receives standard care for Type 2 DM while the treatment group (n=247) receives standard care plus the NCM/MI intervention (at no charge).

It is the aim of this paper to report on how a group of initial participants make meaning of the MI intervention one year after enrolling in the study.

Design/Methodology Overview

Sample/Participants

Participants in the RCT had to be adults (>21 years), a patient in one of the 8 participating clinics, diagnosed with Type 2 DM, and with HgA1C >7.5 (The three primary co-morbidities associated with poor outcome in Type 2 diabetes were the specific aims of the larger study.)

Enrollment rate averaged 22%. Reason for nonparticipation included time (∼20%), transportation issues (∼15%), other competing health issues (10%), denying they needed help (∼25%), no reason (10%), other family responsibilities (5%).

Descriptive statistics were used to analyze baseline demographic data. Zero percent of participants were at goal as compared to 7% nationally.

Intervention

Prior to beginning recruitment for the RCT, three experienced registered nurses received four months of specialized education in Type 2DM, case management, and motivational interviewing. Techniques for learning MI included role plays, lectures, videoconferencing, journal article reviews, attending a conference, and mock interviews with standardized patients. They were provided continuous feedback from experts via observations of live performance, feedback from audio and videotapes, and regular standardized analysis of taped visits to assure fidelity.

An evidenced based protocol was developed for case management of Type 2 DM so the study nurses could work in collaboration with PCPs. The protocol addresses management of blood glucose, hypertension, hyperlipidemia, and depression, and is based on the American Diabetes Association's Clinical Practice Recommendations, and the Institute for Clinical Systems Improvement (ICSI) guidelines.

Clients are initially seen at 2, 4, and 6 weeks, and then at a minimum of every 3-6 months thereafter, although the schedule is tailored to individual preference, as needed. They can email or telephone the nurse as often as needed between visits. The intervention phase of the study lasts two years.

In addition to a standard nursing assessment, an initial study visit includes a status report on lab values, medication review, exploration of the patient's goals, and evaluation of current satisfaction with diabetes management in specific, and health status in general. Rapport is established by using a non-judgmental approach, understanding other aspects of patient's life, and active listening. Typical intake visits last one hour, with subsequent visits varying between 15 minutes to one hour.

Ongoing visit protocols vary, with safety issues being a priority of any encounter. The study nurses use MI techniques to identify ‘the agenda’ which, if any, self care behaviors the patient would like to change.

Current Study

One year after recruitment level of ∼80% achieved, focus group methodology was used to evaluate how patients felt about the nurse-led motivational interviewing intervention. Four groups were held at staggered intervals to permit full participation. The facilitator was Ph.D. prepared counselor with expertise in conducting focus groups.

The interviews were taped and transcribed for analysis. A total of 19 participants contributed to the focus groups.

• 10 male, 9 female

• Ethnicity

  • –10 non-Hispanic white
  • –8 Hispanic
  • –1 African American

Average age 62.1

Ethical Considerations

Prior to the implementation of the RCT, approval from the university IRB was obtained. Physicians at the eight clinics used were then oriented to the study and given the opportunity to opt out any or all of their patients from being approached to participate. Potential participants were then mailed a letter describing the study. This letter was signed by their PCP and stated that the patient would be approached about participation during a clinic visit.

Trained recruiters then approached patients using a standardized script which offered the opportunity to be involved in the study, where one group of patients would see a specially trained nurse who would work closely with them and their doctor on things that were important to their diabetes. The other group of patients would complete questionnaires at regular intervals only. Both groups would continue to receive standard care. At this point, written informed consent was obtained.

To obtain participants for the focus groups, nurses approached individuals in their caseload who had been part of the study for one year, and described the purpose of the groups. Although the nurses were blinded to the names and number of participants from their caseload, an estimated 50 % of those approached consented to participate; the most common reason for refusal was lack of time.

Data Analysis

Each focus group dialogue was taped, transcribed, and validated prior to evaluation. Interpretative Phenomenological Analysis (IPA) was used to analyze the data. IPA is a qualitative method for analyzing data based on phenomenology and intended to uncover how patients/participants interpret and make meaning of experiences. Developed by Smith (2004), IPA is concerned with individual perceptions as well as how the professional interprets those perceptions. Smith advises that when using focus groups to collect data, the transcripts be reviewed twice: first to look at group patterns and then for individual parallels. Others have proposed that with the right conditions, disclosure may actually be enhanced in focus groups (Wilkinson, 2003).

Accordingly, the research team met to review the transcripts first on a group by group basis and then across groups to identify themes around the impact of a nurse-led MII intervention on the lives of patients. These themes were then compared and contrasted to what the team understood as “standard practice” in diabetes care.

Based on participant statements, the following responses to the intervention were identified:

Gentle Accountability vs. Shame and Blame

Through their interactions with the nurses, participants gained several insights. A key one was their desire for a regular check-in about their self care which did not involve policing, scolding, or being treated like a child. A respectful but regular evaluation and assessment of their self care behaviors helped keep awareness of their importance in the forefront.

One participant said:

“….I found meeting with the nurse and having the discipline to sit down, discuss things, get a game plan, got me back on track.”

In particular, the way in which nurses presented feedback (nonjudgmentally) was beneficial, as described in this statement:

“She's very positive about everything you know she doesn't come down on you for and I appreciate that because ah I've been I guess I've been pretty angry from the beginning that I even have it…”

The accountability was almost on a subconscious level, and introduced subtly by the nurses during the course of the sessions.

Another noted:

“…it's a lot more easier and you're expressing what problems you're having and you know the good sides of it the bad sides of like she says oh your A1C is up. Well, okay I know, well I didn't have any insulin for awhile you know it's gonna be up for awhile a 7.1 to an 8, yeah, you know. And she explains what you have to do next and that's it.”

As part of accountability, patients examined their situations and decided which, if any, self care behaviors they were willing to address. Since goal setting occurred with the patient's permission and at his/her initiative, the feedback/accountability process became a discussion rather than a disagreement or dictate.

Said one:

“…we'll work together to set goals, together and I find it very helpful…I used to eat a lot of sweets and one of my goals is to get away from that…that's kinda hard for me yet to adjust to that yet but it helped me to set goals.”

Another person commented:

“She kinda follows up from the last appointment and says now you said that you were going to try and how's that working, you know, and you were going to try to do this and that. And it is the accountability factor is a big factor I think ….”

Even when patients had “slipped” and their labs were not ideal, they still felt the nurses were gentle and withheld blame. They said:

“They never come down on you. She makes you feel very relaxed and calm.”

“She's very kind I really like her a lot.”

“I know I get very upset with my blood sugar and when I go in xxx will say to me why are you upset? These are good readings….And she doesn't get angry or anything…”

“The accountability….I made the mistake of telling [the nurse] but I should have never told her, but in a way it was good, I said, ‘I go to Weight Watchers,’ so we weighed me and we got all excited and now every time I go to her she brings the scale and I'm like, ‘Go away!’ but it's a positive, a positive…”

“Coming along side” a patient rather than engaging in power struggles over needed behavior change often led patients to willingly take on the responsibility and appreciate the opportunity to do so.

One said:

“Taking responsibility for it and you know and I find it I find it ah very beneficial and very supportive. It isn't that you get any revelations of things you don't do but it just keeps you on track, you know…”

Providing What Was Needed vs. “Prescribing” by Protocol

As part of case management, nurses identify resources and provide for patient needs, among other functions. However, focus group participants reflected on the way in which the study nurses were able to go beyond allocating supplies and understand what their true priorities and needs were. In this way, they received not what the nurses believed they needed or what the standard treatment plan suggested was appropriate, but what the patient truly valued, even if these two were different. (When safety concerns were detected by the nurses, i.e. suicidal behaviors, dangerously high blood sugar levels, etc., M.I. was set aside and the immediate life threatening concern addressed as a crisis.)

For an example of “providing what was needed,” one participant who admitted to being afraid of testing her blood sugars began regular monitoring after visiting the study nurse. The patient said: “They (nurse) changed my, you know, the needle.” As it turned out, the lancing device of the patient's monitor had been set too forcefully, and she had not been aware that she could use other sites than her finger for testing. The study nurse was the first person who explored what led the patient to avoid monitoring, rather than just noting that she did not or stressing the importance of doing so.

Along with learning new information from the nurses, patients had their doctor's orders clarified and described:

“She really goes into detail and explains and there are a lot of problems that I have well my doctor she doesn't really explain to me and I'll ask her, she'll even go on the computer and look up things. My labs or if I have a questions about something she'll explain it.”

One person described it this way:

“…I feel comfortable, that I can bounce things off of her… and there is a lot of little things I think that I can bounce off the nurse. She can help me with little things, is this your diet, is this any good? What do you do, what shouldn't you eat, when do you eat it?”

Support Through Denial and Depression vs. A Focus on the Physical

Often, health care providers tend to focus on physical symptoms and adjust patient care accordingly. In these groups, as patients talked about what the nurses did for them, they often spoke of the difficulty coping with the reality of a chronic illness—in fact, this was one of the reasons for refusing to participate in the study, i.e.

“My diabetes isn't that bad.”

Consequently, the nurses were able to listen to the feelings and emotions patients had about their illness before jumping in to check lab results or listen to heart sounds. This ability to “sit with” patients as they grieved the loss of “normalcy” led to beginning acceptance of chronic disease, as evidenced by this narrative.

“Patient: Well I kind of have a hard head I guess um if you don't know too much about it then you don't have to worry as much.

Facilitator: So you just wouldn't seek information?

Patient: I would tip toe around it. I wouldn't see it. I would read some things and I would go on.”

One person described the nurse's openness to his input this way:

“…I feel comfortable, that I can bounce things off of her… and there is a lot of little things I think that I can bounce off the nurse. She can help me with little things, is this your diet, is this any good? What do you do, what shouldn't you eat, when do you eat it?”

One patient described the relationship with the nurse this way:

“It's not as stressful… you get very agitated and don't want to deal with people anymore cause no one is listening to you.”

The use of MI allowed patients to feel supported and understood in a difficult circumstance. Some comments include:

“And as an adult you want to be treated as an adult not as a child that you don't know what you're doing.”

“…Um, you know she is always encouraging and it's a difficult disease to manage and I get little help at home so having some help somewhere, I'm grateful for it.”

“It's like you want to tell somebody else that really cares and they don't understand so then I just go into my denial thing. But [the nurse] has gotten me out of that, that's what the good part is. I talk about it more, you know: ‘I am a diabetic’… now it's a little bit easier to deal with…”

Communication Skills That Connected to True Concerns vs. Checks in Boxes

Beyond therapeutic communication skills that nurses use to obtain required information, the nurses used MI in a way that provided the opportunity for patients to take the lead in identifying their feelings about changing behavior. Some comments about the nurses' communication skills include:

“It's in the way she presents it. It's really kind of a laid back manner. It's not standoffish or a lecture.”

“For some reason I respond better to her input than I do to (Dr. X) even though they say the same … [when A1c dropped]…..she was like celebrating it like all over…I think that makes it more personable and she knows everything about me. She listens so well….I don't know what I would do without [nurse] right now..”

“And I think the other thing is to when I sit there with [nurse]even though when I'm with my doctor it's one on one when I'm sitting there with [nurse] she's looking me straight in the eye, like this with me, like she comes into the conversation….”

“And she comes in and she does that thing and I do know it's my responsibility…I don't have to pull it, I don't have to be the one, she comes you know kinda like this body language. She sits, I mean she comes up into me, okay now lets talk.”

Many of these techniques go beyond the standards of therapeutic communication and reflect the core techniques of MI, i.e. acknowledging ambivalence, coming alongside the patient, etc. Doubtless, some of these perceptions arise from the fact that the study nurses had the benefit of more time to spend with patients. Each visit was allotted one hour, so the pressure to turn patients over, so much a part of the regimen of usual clinic practice, was not an issue.

Motivating and Empowering vs. Negative Feedback

Although it was not the role of the nurse to be the motivation for the patient, it was their role to empower patients and draw on underlying motivations toward change. As such, patients were frank in saying: “She's the one that keeps me motivated, so you know that's good.”

When asked to elaborate on what the nurses did that was motivating, another patient said:

“Just being around her. The way she explains things. The way she treats you, everything.”

Another described an element of hope they felt when interacting with the nurse:

“She does everything, I think she does anyway on a positive level. And she's very reassuring. Everything that she explains to you. It's not the end.”

The idea of the nurse helping patients accomplish goals for themselves was expressed by this patient:

“…she'll still go to bat for me. She may not be happy with the answer but it's like another advocate for me….I love being able to talk to her. And she's so, I don't know, …just a wonderful person. I don't know what I'd do without her. One of the few people that I've really talked to and met that I feel like I've got accomplishments done…”

Another patient described how she was feeling badly about her A1C level until she talked to her study nurse:

“…and she went (laughter) noooo, you're fine don't worry about it. You're doing wonderful because, you know, I'm concerned that it should be at like 4.7 or something like that, you know, and she says: ‘no, we're very happy where you are at, now don't get all worried about it…”

“…even if I didn't lose any or I gained, she just doesn't do what we were talking about: ‘Bad, bad!’, she says, ‘Well that's okay, you're doing okay,’ and that's when I think you most want that positive reinforcement from somebody…”

For comparison of statements that might be made during the course of a “normal” patient encounter and one in the study which used MI, please see Figure 2.

Figure 2.

Examples of Responses That Capture Themes

Nursing Analysis

In processing these findings, the study nurses believe the focus group statements are generalizable to the larger RCT study. Their observations of participants in their caseloads support the validity of the themes derived from the focus group feedback and confirm that the larger group of patients are experiencing a beneficial impact of the intervention. Measurable behavioral changes such as weight loss, lab values normalizing due to medication or lifestyle change, more trust and better rapport with PCPs, openness and sharing confidences with the study nurses, and describing the nurses as their advocates were all concrete examples of positive outcomes. Not surprisingly, depression and stress management are two issues that nurses reported addressing in their visits with study participants.

The nurses note that PCPs generally overestimate adherence, whereas providing empathy and being nonjudgmental facilitates accurate reporting of self care behavior by patients. They also describe MI as a technique which allows “natural nursing tendencies toward empathy” to be made manifest. Barriers to care such as provider availability, transportation access, suspicion, and mistrust have been removed as part of the intervention. Although clinical inertia is considered a common problem in diabetes medical care, the nurses' experience is that patients often did not make prescribed behavior changes because they were not ready, or for easily remedied reasons unknown to the physician. MI is a strategy that the nurses find effective in helping them to facilitate a patient's acceptance of PCP recommendations, such as taking a new medication, monitoring on a regular basis, and/or taking insulin.

Summary

In comparison to standard practice, patients responded to MI style visits from trained nurses in a way that led to beneficial health outcomes. Since the study is ongoing, data has not been analyzed, but nurses note that many of their patients have achieved behavioral goals for the first time.

While the protocol for this study is skewed to allow the nurses time and flexibility with patients (their caseloads are reasonable and relationships with patients were, at the time of this study, ongoing for over a year) key aspects of the intervention are identified here so as to enhance translation into usual care.

Summary of Key Findings

Preliminary baseline analyses revealed that all study participants (control and treatment group) had more diabetes-related psychological distress, lower adherence to most self care behaviors, lower satisfaction with treatment, and more depression than generally reported in the literature. They are, therefore, a group at risk for poor outcomes.

Results of our focus group analysis reveals that the intervention has had a positive impact on some psychological parameters not measured in our quantitative instruments. For example, patients felt empowered to make lifestyle changes related to nutrition and exercise, and their confidence in their ability to handle challenges improved. It is important to note that many of the focus group comments suggested that the nursing knowledge and professional background enhanced the MI component of the intervention.

In the bimonthly newsletter developed for treatment group participants, volunteer patients shared dramatic stories of their enhanced ability to accept their disease, lower stress levels around specific self care behaviors such as monitoring, coping more effectively with chronic illness, and taking a more active role in self-management have been reported.

Conclusions

MI is a therapeutic communication strategy that has great relevance for both nursing and medicine. When working with patients whose chronic illnesses require self care and monitoring, this technique allows PCPs, nurses, and patients to function as a true team. Deciding when it is more appropriate to use MI or standard health care approaches is one challenge that emerged, and specific training strategies for medical personnel (as opposed to therapists and counselors) are indicated.

We found that MI is feasible to use and well accepted by patients in the primary care setting. While it is different for patients to be placed in an active role, initial resistance (especially among older adults) can be effectively transformed into active participation. Nurses felt this intervention led to better relationships with PCPs, empowering of patients, and support of self-efficacy. Their sessions to promote behavior change were described as: “more of a dance than a wrestling match, as usually occurs.”

Figure 1.

Table 1.

Baseline Patient Demographics:

Demographics:	% of total or M
Age (M)	58 years
Gender:
Females	56
Race/ethnicity:
-Hispanic or Latino	37
-Asian	1.4
-Black or African American	6.6
-Caucasian	53.2
-Other	1.9
Height (M in inches)	65″
Weight (M in pounds)	210.6 lb
Highest level of education:
-less than high school;	27.4
-high school;	30.3
-some college or vocational program;	17
-college graduate	12.8
-postgraduate, professional degree	5.5
Average income:
-less than $15,000	38.4
-$15,001-20,000	9.4
-$20,001-35,000	9.9
-$35,001-50,000	8.9
-$50,001-65,000	6.3
-$65,001 or greater	14.4
Marital status:
- single	15.9
- married	51.7
-divorced	11
-living apart	5.5
-widowed	10.4