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Using motivational interviewing to encourage behaviour change Have you ever experienced trying to get patients to change their lifestyle choices? Motivational interviewing could benefit you, your patients and clinical practice by eliciting positive behaviour change, as renal physiotherapist Vicky Pursey explains.

n motivational interviewing n behaviour change n lifestyle change n health promotion n collaboration

C linicans can spend a lot of time and effort trying to get patients to change their behaviour for the benefit of their health, but so many do not do what

they are told. Blaise Pascal in his writings Pensèes, published in 1670, suggested that ‘people are generally better persuaded by the reasons which they themselves discover than by those which have come into the mind of others’ (Pascal, 2005). Assuming this is true, why do health professionals try to get patients to engage in their health care by telling them what to do in a directive manner?

For kidney patients, chronic disease can often require significant changes to their lifestyle, such as: attending haemodialysis three times weekly; managing peritoneal dialysis daily; taking significant quantities of medication; doing more exercise despite the fatigue often experienced; and restrictions being imposed on fluid intake and diet. Martino (2011) describes how patient motivation to self-manage tends to wane as disease progresses. Therefore, getting kidney patients to collaborate with health professionals can be challenging.

However, links between patient empowerment and reduced mortality have been the subject of several studies summarised by McCarley (2009). These support the concept that partnership rather than prescribing approaches should benefit kidney patients through maximised clinical outcomes, reduced disease burden, and improved quality of life; and benefit practitioners through reduced frustration at non-adherence to treatment. Using a behaviour change technique known as motivational interviewing (MI) can achieve improved patient engagement with treatment in those with chronic health problems, such as kidney disease.

What is motivational interviewing? MI is a conversation technique between two people that aims to focus on enhancing one party’s intrinsic motivation to change their behaviour in a positive way. In the context of this article, MI is specifically between a health professional and a renal patient with a focus on kidney health promotion and a change of behaviours that may be beneficial to their medical condition.

There are several important concepts that underpin MI: a patient-centred approach focusing on self-motivation; allowance for the person to explore and resolve their ambivalence to change; and collaboration between the patient and health professional, the latter party using developed listening skills and a guiding style in contrast to a directive style of communication.

Behaviour change is central to health promotion in renal patients as they have a chronic disease burden which is not curable, may worsen without appropriate treatment, and can affect systemic health and patients are often expected to follow restrictive diets to maintain an acceptable biochemical balance. Therefore, all members of the multidisciplinary team should understand and apply behaviour change techniques across the scope of their clinical practice, to enhance their patients’ outcomes.

Most health professionals are familiar with using methods of communicating with patients in a directive and instructional manner. Therefore, using MI techniques in daily patient management is an approach that may be quite novel to some practitioners. Considering that clinicians talk to their patients regularly, incorporating MI techniques as part of the normal conversation is theoretically achievable with ease. However, it does take practice to change communication technique and style and to feel at ease using MI with renal patients. Nevertheless, with considerable practice, health professionals may find a positive response to their attempts at doing this.

Victoria A Pursey n Renal Physiotherapist, York Hospital, York n [email protected]

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Does motivational interviewing work with kidney patients? Most evidence for using MI with patients stems from the social care environment, often in the treatment of addictive behaviours. Evidence for effectiveness is mixed and is often based on a variety of studies where benefit is not always clear, although some studies have shown that these interventions can be effective in alcohol abusers and smokers (Lai et al, 2010; McQueen et al, 2011). However, a comprehensive literature review by Cummings et al (2009), supported by Lundahl et al (2010), strongly suggests that MI has significant small positive effects across a wide range of problem presentations, works well for some patients but not others, and works better in some situations than others, but overall is likely to enable a positive benefit for patients. In older adults with acute and chronic illnesses, significant behavioural changes in domains of physical activity, diet, cholesterol management, blood pressure control, glycaemic control, and increased smoking cessation following MI intervention were found (Cummings et al, 2009; Lundahl et al, 2010).

Therefore, MI is likely to be an effective and useful behaviour change tool in patients with chronic kidney disease. Renal patients come into contact with a myriad of health professionals regularly—dietitians, haemodialysis and peritoneal dialysis nurses, pharmacists, physiotherapists, consultants, transplant nurses and social workers—so behaviour change could be desirable across many different domains. MI, therefore, is one of several techniques that may offer flexibility in optimally managing the health concerns of this patient group, bringing sustainable behaviour changes, driven by patients themselves.

Practical application of motivational interviewing MI is a conversation tool and, therefore, relies on communication and listening skills. In addition to the core principals above, there are certain aspects that the practitioner needs to understand and utilise. Firstly, there needs to be an understanding that many patients will not change a particular behaviour just because a health professional tells them to, although some will. Even if the person does readily change one aspect of behaviour they may be ambivalent about changing another. This is where a health professional tries to correct patients by offering them the solution the health professional believes to be the best. However, in MI, the patient requires autonomy.

MI is a process and usually not just one conversation but a series of conversations. Open questions are essential for MI to start and guide a conversation in order to find out what the patient already knows about the subject, where they may

have misconceptions that they can be corrected and educated on, and what areas they might be willing to contemplate or change (Rollnick et al, 2008).

Ambivalence to change and the ‘righting reflex’ If health professionals encourage patients who are not ready to make any behaviour changes, they may ignore advice, not carry out the advice as suggested, or simply agree to change without intent just to stop any further lecturing. This is because the patient’s ambivalence is not being acknowledged.

Health professionals may often use language such as, ‘You should’, ‘You ought’ and ‘You must’ to try and affect behaviour change in patients. A common method is to tell patients all the reasons why they should adopt a particular behaviour. This desire to instruct, advise and correct the patient is defined in MI terms as the ‘righting reflex’ (Miller and Rollnick, 2002). Telling a patient what to do for the better leaves them with the converse rationale. For MI to work effectively, clinicians have to resist telling patients what to do and let them work it out for themselves—they have to resist the ‘righting reflex’.

Below are some examples of direct conversations with renal patients:

n ‘You ought to go to the gym as you will feel a lot better and might be less breathless climbing stairs if you persevere’

n ‘You have paid a lot of money for the gym membership so you should use it’

n ‘If you really want to feel better, you must take your medications properly and regularly’

n ‘You have put on a few pounds, and you will not get your kidney transplant if you do not lose two stone. You need to do more exercise. I think you should go for a jog every day’

n ‘You should learn to put your own needles in for dialysis. You ought to try it as I think it would be better for you.’

Common responses from the patient may include: n ‘I am a bit tired today so I would rather go straight home really’

n ‘I will try and go three times next week so it will not be such a waste of money’

n ‘I do not like taking my medicines, they make me feel terrible. Perhaps it is the side effects’

n ‘I have to cook dinner and tidy up so I struggle finding time to exercise; and I hate jogging’

n ‘The thought of putting my needles in is really scary, so I would rather you did it for me. I think I would get it all wrong and it could be very painful so I don’t want to try.’

Health professionals should allow patients to weigh up the pros and cons of why they should make a change for themselves. They are more likely to give

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consideration to making achievable and successful behaviour change this way. This also enables health professionals to acknowledge the patient’s ambivalence to change.

Successful questioning, education and correction of misconceptions Open questions are vital when starting a conversation with a patient where behaviour change is desired. This provides a starting point for exploring the patient’s knowledge of the subject, understanding any misconceptions, and any ambivalence to change. Open questions are those generally starting with ‘Where’, ‘What’, ‘How’ and ‘Why’. Caution is advocated with the use of ‘Why’ as this may be perceived as threatening or confrontational. Instead, health professionals should try to use phrases such as:

n ‘Tell me more about that decision’ n ‘Explain for me your thought processes on that’ n ‘Describe to me what made you come to that conclusion’

n ‘Help me to understand what made you…’ In eliciting behavioural change, education may

be required, particularly where there are gaps in the patient’s knowledge or there are misconceptions.

These may be on any aspect of health but for renal patients could include misconceptions as to the levels of salt in common foods, or the likelihood of side effects of phosphate binders. When educating patients, health professionals should use phrases such as, ‘Would it be OK if I told you about the risks of not being active/the dangers of smoking/the problem with too much salt in your diet?’ This should be followed up with asking how the renal patient feels about what they have just been told. Not all patients will welcome this information; if they refuse to discuss the subject, health professionals should avoid lecturing them or using scare language to imply that if they fail to comply something adverse may happen.

Change talk, reflective listening and affirmations Active listening is necessary to recognise and reflect the patient’s thoughts and feelings. These reflections, or affirmations, reinforce the patient’s stage of behaviour change. In order for health professionals to find out whether they are ready to change, they will need to identify ‘change talk’. Change talk is language that patients use that indicates at what point they are prepared to make a change. Change talk is a concept used in behaviour change techniques, including MI.

When patients are contemplating making changes to their behaviour they will use certain phrases and words that indicate this. Health professionals should listen out for these and reflect them back to the patient, i.e. repeat them, paraphrased, back to the patient. This reinforces that the health professional is listening and that they recognise the patient’s ambivalence, as well as emphasising his/her motivation to change. As such, patients hear their sentences twice. This opportunity can be used to add open questions to focus the patient’s motivation and evoke action for change. Change talk can be categorised into four areas (Box 1).

Responses to these four categories, might include: n ‘So from what you have told me you would like to exercise more. What would stop you doing that?’

n ‘You mentioned you should lose some weight. How could you do that?’

n ‘You might be able to reduce the salt in your diet. Tell me about how you will achieve that.’

Following on from this, the health professional can support a person’s qualities and strengths by using affirmations in their conversation. This is a powerful tool to build rapport and demonstrate empathy. Affirmations should be genuine, and either positive or neutral comments. They reflect and recognise a person’s efforts to change. Examples could be:

n ‘You seem very resilient to set-backs in the past when trying to lose weight’

Box 1. Four areas of change talk

Desire (preference for change), for example: n I want to eat less salt n I would like to exercise more n I wish I could put myself on dialysis

Ability (self-capability), for example: n I can do more exercise n I could take up swimming n I might be able to go to the gym once a week

Reasons (specific arguments for change), for example: n I would feel better if I was fitter n If I did more exercise it would help me be more mobile

Need (obligation to change), for example: n I ought to lose weight to get on the transplant list n I have to try and do some running regularly n I really should stop eating bacon sandwiches daily

Box 2. Prompting questions

n ‘What might be your next step?’ n ‘What would have to happen for you to take more exercise?’ n ‘What would your life be like 2 years from now if you do/don’t start swimming?’ n ‘How do you plan to carry out walking to the shops every day?’ n ‘What’s the worst thing that could happen if you went to the gym?’

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n ‘It sounds like you have had to be determined/ keen/strong in making the changes you have managed already’

n ‘I get the sense that you want to stop smoking, but have worries about…’

n ‘You say you do not feel you need to be any more active. What do you think it would take to make you change this in the future?’

When listening, health professionals should give patients time to speak. Short silences can be helpful in getting patients to talk openly. However, long silences can make them feel uncomfortable.

The last stage of the conversation involves using prompting questions (Box 2). The health professional can conclude the discussion by highlighting what changes they have agreed to make and set some achievable goals. Further conversations can be held to support the patient with their lifestyle changes.

How to react to negative responses It is unlikely that one discussion will have a desired effect from the viewpoint of the health professional or a beneficial change on the patient. It is likely that several sequential discussions will be required. Although, patients may intend to change after the first conversation (Butler et al, 2013). Conversely, some renal patients are not ready to make changes despite a clinicians best efforts. A patient may make slow progress or remain ambivalent; for example, patients may struggle to adopt exercise regimes due to the time demands of dialysing three times a week and the fact they often feel fatigued. In these situations, using the patient’s negative comments might also turn this around into an opportunity for evoking motivation. Reflecting back more extreme statements and the use of paradoxical statements can produce a positive response from the patient; however, it is important to note there will be a risk of resistance from them.

Sobell and Sobell (2008) and Rollnick et al (2008; 2010) give examples of how to use these techniques effectively. Using paradoxical statements aims to make the patient feel taken aback by an unexpected stance from the health professional, allowing them to recognise that they need to change, for example:

n ‘You have told me that you are not doing any more exercise although you acknowledge the benefits, perhaps you are not ready to change this at the moment’

n ‘You say that we all have to die of something and you would rather be happy carrying on smoking, so perhaps you are not ready to stop.’

However, when using this style of reflection, the health professional should be prepared for the patient to agree they do not want to change, cannot see any reason for change, and remain resistant to change.

Conclusion MI takes time and practice to become integral to the day-to-day relationships between patients and health professionals, be it in trying to get patients to engage with shared dialysis care, to follow dietary advice, or to take their medications appropriately. MI techniques can help renal patients accept responsibilty for self-management and implement lifestyle changes to benefit their health. This in turn will maximise their outcomes, improve use of resources, reduce frustrations for both patients and clinicians, reduce wasted time and effort from clinicians, improve professional patient relationships, and encourage sustainable lifelong health benefits.

References Butler CC, Simpson SA, Hood K et al (2013) Training practitioners to

deliver opportunistic multiple behaviour change counselling in primary care: a cluster randomised trial. BMJ 346: f1191

Cummings SM, Cooper RL, Cassie KM (2009) Motivational interviewing to affect behavioral change in older adults. Research on Social Work Practice 19(2): 195–204

Lai DTC, Cahill K, Qin Y, Tang JL (2010) Motivational interviewing for smoking cessation. Cochrane Database Syst Rev Jan 20; (1):CD006936

Lundahl BW, Kunz C, Brownell C, Tollefson D, Burke BL (2010) A meta- analysis of motivational interviewing: twenty-five years of empirical studies. Research on Social Work Practice 20(2): 137–60

Martino S (2011) Motivational interviewing to engage patients in chronic kidney disease management. Blood Purification 31: 77–81

McCarley P (2009) Patient empowerment and motivational interviewing: engaging patients to self-manage their own care. Nephrology Nursing Journal 36(4): 409–413

McQueen J, Howe TE, Allan L, Mains D, Hardy V (2011) Brief interventions for heavy alcohol users admitted to general hospital wards. Cochrane Database Syst Rev 10(8): CD005191

Miller WR, Rollnick S (2002) Motivational Interviewing: Preparing People for Change. 2nd edn. Guilford Press., New York: NY

Pascal B (1995) Pensèes. Translated by Krailsheimer AJ. Penguin Group, London

Rollnick S, Butler CC, Kinnersley P, Gregory J, Mash B (2010) Motivational interviewing. BMJ 340: c1900

Rollnick S, Miller WR, Butler CC (2008) Motivational Interviewing in Healthcare: Helping Patients Change Behaviour. Guildford Press, Guilford

Sobell and Sobell (2008) Motivational interviewing strategies and techniques: rationales and examples. http://tinyurl.com/3jccp6u (accessed 11 September 2013)

Key points

n Health professionals should try to resist the ‘righting’ reflex and use of ‘you should’, ‘you ought’ and ‘you must’

n Health professionals should encourage patient autonomy n Clinicians should avoid lecturing, coercion and persuasion to change and should acknowledge ambivalence to change

n Open questions can help patients identify the need for a change in lifestyle n Patients should be supported to set achievable goals

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