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Motivational Interviewing in Dialysis Adherence Study (MIDAS).

Goal

To provide an overview of the motivational interviewing technique as applied to patients with chronic kidney disease on hemodialysis.

Objectives

1. Define motivational interviewing.

2. Explain the process of motivational interviewing in the healthcare setting.

3. Discuss the benefits of using the motivational interviewing technique with patients with chronic kidney disease on hemodialysis.

Chronic kidney disease (CKD) has steadily increased in prevalence in the United States (United States Renal Data System [USRDS], 2009). In-center hemodialysis is the most common treatment for Stage 5 CKD, with over 341,000 individuals currently receiving this therapy (USRDS, 2009). Adherence to the long-term, complex regimen leading to successful hemodialysis treatment has been shown to be challenging, with rates of non-adherence from 2% (Leggat et al., 1998) to as high as 86% (Bame, Peterson, & Wry, 1993). The World Health Organization defines adherence as "the extent to which a person's behavior (taking medications, following a recommended diet, and/ or executing life-style changes) corresponds with the agreed recommendations of a health care provider" (Sabate, 2003, p. 13). Successful hemodialysis therapy requires adherence to dialysis treatment, diet recommendations, medication prescriptions, and goals for interdialytic weight gain (IDWG). Diet intake of sodium and potassium must be limited since excretion by the kidney is compromised. Medications, such as phosphate binders, must be taken as part of treating kidney failure to avoid long-term complications of the disease and associated morbidities. Fluid intake must be restricted since the failing kidney cannot excrete excess fluids. The Dialysis Outcomes and Practice Patterns Study (DOPPS) revealed that non-adherence significantly increases the risk of hospitalization and mortality (Saran et al., 2003). Non-adherence with dialysis treatments, diet, medications, and fluid intake may result in nausea, weakness, metabolic disturbances, bone demineralization, pulmonary edema, cardiovascular damage, and death (Bame et al., 1993; Chan & Greene, 1994).

A recent review of the literature indicates that patient demographic predictors have not been consistently correlated with non-adherence (Russell, Knowles, & Peace, 2007). Several studies have identified factors that predict the various types of dialysis non-adherence that might be amenable to intervention (for example, depression, self-efficacy, social support, illness perceptions) with inconsistent results (Berman et al., 2004; Kim & Evangelista, 2010; Kovac, Patel, Peterson, & Kimmel, 2002; Kutner, Zhang, McClellan, & Cole, 2002; Russell et al., 2007, 2008; Taskapan et al., 2005; Welch, 2001). Hemodialysis adherence intervention studies using randomized controlled trial designs were recently reviewed with the most effective interventions, including both cognitive and behavioral interventions (Matteson & Russell, 2010). Though the study methods had many weaknesses, six of the eight studies showed statistically significant improvements in adherence with cognitive or cognitive/ behavioral interventions.

An innovative intervention called motivational interviewing has shown promise as an effective approach to improve and maintain treatment adherence in diverse populations (Burke, Arkowitz, & Menchola, 2003; Dunn, Deroo, & Rivara, 2001). Motivational interviewing, delivered by the healthcare provider, is a client-centered, semi-directive method of tapping into the individual's motivation to change behavior by developing discrepancy between current and ideal functioning, and exploring and resolving ambivalence within the individual (Miller & Rollnick, 1991). The goals of motivational interviewing are to establish rapport, elicit change of behavior talk (such as statements indicating desire or ability to change behavior), and establish commitment language from the individual (Miller & Rollnick, 1991). This communication technique between the patient and healthcare provider supports individual autonomy and seeks to enhance treatment adherence (Rollnick, Miller, & Butler, 2007).

The general steps of motivational interviewing are as follows. First, the healthcare provider expresses empathy toward the patient about the difficult-to-change behavior through acceptance and reflective listening. For example, the provider might say, "I hear you saying that taking your medications on time every day is hard to do. Sometimes you just want to be normal and not take any medications. You are tired of trying to remember your medications every day." The provider may also provide affirmations, such as, "It is tough to continue all the work needed to keep you healthy so you can enjoy life and your family. Staying healthy is important to you." Summarizing the conversation periodically is also appropriate.

Next, the healthcare provider helps the patient develop discrepancy between current behavior and goals or values that are important to the patient. For example, the provider might point out that not taking prescribed medications is inconsistent with the goal of being on the transplant list. The provider might also use the Importance and Ability Ruler. In this approach, the provider asks, "On a scale of 1 to 10, with a 1 being not important at all, and a 10 being very important, how important is it for you to take your medications on time every day?" Once the patient responds (for example, with a 7), the provider seeks to have the patient verbalize the reasons why taking medications is important; the provider then asks "Why did you choose 7 and not a 4 (some lower number)?" Once the patient expresses the reasons for the importance of medications, the provider can support this language. Readiness to change should also be assessed using the Importance and Ability Ruler. The provider asks, "On a scale of 1 to 10, with a 1 being not ready at all, and a 10 being very ready, how ready are you to make changes so that you take your medications on time every day?" When the patient responds with a number (for example, with a 6), the provider asks, "Why did you choose a 6 and not a 3 (some lower number) ?" When the patient provides a rationale, the provider asks, "what would it take for you to feel like you could get from a 6 to an 8?" The goal of motivational interviewing is to elicit change talk from the patient because a person becomes committed to something that is stated.

The goal is that the patient states the positive side of the argument, not the negative side, with traditional interactions. The patient might say, "I want to stay healthy, and taking my medications can help me reach that goal."

The provider seeks to reinforce and encourage continued change talk in the patient. One method to achieve this goal is to ask the patient to identify the "cons" of staying the same. The provider may ask the patient, "what worries you about the status quo? What will happen if you don't do anything?" The provider tries to elicit the "pros" of changing by asking, "What will happen if you make the change? How would you like things to be different?"

Motivational interviewing has been effective in changing behavior related to HIV, diabetes mellitus, hypertension, smoking, alcoholism, gambling, drug abuse, bulimia, and obesity (Amrhein, Miller, Yahne, Palmer, & Fulcher, 2003; Group, 1997; Resnicow et al., 2001; Steinberg, Ziedonis, Krejci, & Brandon, 2004). In a systematic review of motivational interviewing intervention studies across behavioral domains, 59% of the studies (17 of 29 studies) found at least one significant positive behavior change outcome (Dunn et al., 2001). Additionally, this brief communication technique has been delivered in a variety of clinical settings by healthcare professionals (Emmons & Rollnick, 2001).

Only one pilot study has evaluated a similar intervention in patients undergoing hemodialysis to improve non-adherence, specifically IDWG (Fisher et al., 2006). Using a case series design with five patients receiving dialysis, cognitive-behavioral therapy and motivational interviewing were used briefly over several sessions by dialysis staff. Cognitive behavioral therapy seeks to change behavior through attitude and belief change. Three of the five patients showed improvements in fluid adherence, and two of three maintained these positive results for at least six months.

The purpose of this pilot study was to examine the feasibility and efficacy of a staff-delivered motivational interviewing technique to improve treatment adherence in adult outpatient patients on hemodialysis. Additionally, the effect of motivational interviewing on adherence to diet and fluid intake recommendations was also examined. Results from this study are urgently needed by dialysis programs because non-adherence is such a prevalent problem. Because dialysis staff members routinely communicate with patients receiving dialysis at key moments to intervene with non-adherence, staff could use motivational interviewing in daily practice to improve motivation to adhere to the treatment regimen.

Methods

Design

A pre-post design was used for this pilot study, with each participant serving as his or her own control. Baseline adherence data were collected for three months. After this, the three-month motivational interviewing intervention was implemented. After the intervention, three months of post-intervention adherence data were collected. Staff continued to use the motivational interviewing intervention during the three-month post-intervention data collection.

Sample/Setting

Twenty-nine participants were recruited from a non-profit, freestanding hemodialysis clinic in the central United States during the months of April and May 2009. They met the following inclusion criteria: 1) 21 years of age or older; 2) ability to speak, hear, and understand English; 3) no cognitive impairment as determined by a score of 24 or above on the Mini-Mental Status Exam; and 4) well enough to participate as determined by the dialysis center nurse manager.

Instruments

Mini-Mental Status Exam. The Mini-Mental Status Exam was used to screen for cognitive impairment, with a score of at least 24 or above indicating no cognitive impairment (Folstein, Folstein, & McHugh, 1975). This examination is a widely used, 30-item, brief (10-minute) assessment for cognition sampling arithmetic, memory, and orientation. Reliability (retest = 0.89; interrater = 0.82) and validity (content, discriminant, concurrent) have been established (Folstein et al., 1975).

Independent variable: Motivational interviewing intervention. Motivational interviewing was delivered for three months by all dialysis staff (nurses, technicians, dietitian, social worker) to the patients receiving dialysis treatment during their routine interactions. All staff members were trained by a motivational interviewing expert (NC) on the use of motivational interviewing during two four-hour training sessions. These training sessions addressed the following topics: motivational interviewing, tools for building motivation for change, responding to change talk and resistance, and enhancing confidence/strengthening commitment. The motivational interviewing expert conducted systematic coaching sessions with each staff member at least once per month for three months prior to the intervention until each staff member was determined by the expert to be proficient in motivational interview delivery. Coaching sessions verified that all staff members achieved competence in their delivery of the motivational interviewing intervention. The motivational interviewing expert observed interactions of staff with patients and completed the Motivational Interviewing Adherence and Competence Feedback Form and reviewed this with each staff member at each coaching session. Additionally, at each session, the Motivational Interviewing Skills Development Plan was completed by the motivational interviewing expert and reviewed with each staff member individually to help staff members identify areas for improvement and develop an improvement plan. Each tool is drawn from the Motivational Interviewing Assessment: Supervisory Tools for Enhancing Proficiency (MIA: STEP) (Martino et al., 2006).

Dependent variables: Non-adherence and autonomy support. Non-adherence was measured for three months prior to the intervention and for three months after the intervention. Data were collected from the participants' medical records, including missed dialysis treatments, shortened dialysis treatments (greater than 10 minutes), IDWG, serum phosphorous, and serum albumin. The National Kidney Foundation Dialysis Outcome and Quality Initiative (KDOQI) outcome parameters as used in previous adherence research were used to determine those who were non-adherent (see Table 1) (Russell et al., 2007, 2008; Saran et al., 2003).

The Health Care Climate Questionnaire is a 15-item measure that assesses patients' perceptions of the degree to which they experience their healthcare providers to be autonomy supportive (a key concept of motivational interviewing) in providing general treatment or with respect to a specific healthcare issue. This tool was used to measure patients' perceptions of effective implementation of motivational interviewing by the dialysis staff. The score for the provider's autonomy support is the average of the 15 ratings, and higher average scores represent a higher level of perceived autonomy support. Alpha reliability for the 15 items has consistently been above 0.90 (Williams & Deci, 2001).

Procedure

Institutional Review Board approval was obtained from the primary investigator's (CR) institution. The study was also approved by the Administrative Review Board at the dialysis clinic where the study was conducted. The dialysis center's nurse manager (MH) identified patients and asked if they were willing to have the research assistant discuss possible participation in a study. Those who agreed to participate were contacted by the research assistant (MM), and study details were discussed. Informed consent was obtained from all study participants. Those meeting inclusion criteria continued in the study. Participant demographic information was collected. The Health Care Climate Questionnaire (HCCQ) was administered to all patient participants. Participant adherence data from the previous three months (dialysis attendance, shortened treatments, IDWG, phosphorus, and albumin levels) were extracted from the medical record. Motivational interviewing training sessions were scheduled and conducted followed by monthly coaching sessions. The motivational interviewing intervention was conducted by the dialysis staff for three months. The HCCQ was again administered to patient participants. Post-intervention non-adherence patient data (dialysis attendance, shortened treatments, IDWG, phosphorus, and albumin levels) were collected for three months after the intervention phase.

Data Analysis

SAS v9.1 (SAS Institute, Inc., Cary, NC) was used by the project biostatistician to conduct all data analyses. Descriptive statistics, including means and standard deviations for continuous variables, and percentages for categorical variables were calculated. The Wilcoxon signed-rank test was used to compare pre- and post-intervention adherence data (dialysis attendance, shortened treatments, IDWG, phosphorus, and albumin levels) and HCCQ data. The non-parametric signed-rank test was used because repeated measures were obtained on the same participants, and data were not normally distributed.

Results

Intervention Effectiveness

A convenience sample of 29 patients receiving hemodialysis was recruited for the study. The flow of participants through the study is shown in Figure 1. The five participants who had incomplete data and were dropped from the study were not significantly different from those who remained in the study with respect to sex, ethnicity, race, cause of CKD, education, employment, time since first dialysis treatment, history of transplant, smoking status, baseline HCCQ, and MMSE (all p values were greater than 0.05).

The demographic characteristics of the participants at baseline are shown in Table 2. The demographics of the study sample are similar to those of patients receiving hemodialysis in the United States (USRDS, 2009). The changes in outcomes (specifically dialysis attendance, shortened treatments, IDWG, phosphorus, and albumin levels before and after the motivational interviewing intervention) are delineated in Table 3. The number and percentage of missed and shortened treatments, and good, moderate, or poor phosphorous and albumin levels before and after the intervention are shown in Table 4. Motivational interviewing appeared to favorably influence dialysis attendance, shortened treatments, and phosphorous and albumin levels. Motivational interviewing appeared to less favorably change IDWG. Changes in the HCCQ scores were not statistically significant from pre(M = 5.96, SD = 1.07) to post-intervention (M = 6.15, SD = 1.01, p = 0.15), although the trend was in the direction of improvement in autonomy support--a main component of motivational interviewing.

Feasibility of Intervention

The feasibility of the motivational interviewing intervention was also assessed in this study primarily through informal feedback from staff delivering the intervention and from patients receiving the intervention. During staff coaching sessions, the motivational interviewing expert observed staff members establishing good rapport with patients and consistently using reflective listening skills and open-ended questions, consistent with a motivational interviewing style. Observations made in the first month of the intervention were not substantially different from those made at the second and third months, indicating that staff continued to develop and use motivational interviewing skills throughout the intervention period. Further, staff members were frequently eager to ask questions during coaching sessions, and most appeared eager to continue to improve their effectiveness with motivational interviewing.

Patients receiving the motivational interviewing intervention commented positively about the change in communication style used by staff. Patients commented they felt staff members were listening to them more. Patients also felt staff were more accepting of the challenges of adhering to the dialysis regimens. No patient participants verbalized that the motivational interviewing intervention was bothersome or burdensome to them.

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Discussion

This pilot study is the first to evaluate motivational interviewing as a stand-alone intervention to improve adherence in adult patients receiving hemodialysis. This is also the first study to involve dialysis staff, not researchers, in administering motivational interviewing to adult patients receiving hemodialysis. Though the findings are not statistically significant, skipped and shortened treatments showed the most improvement. Phosphorous blood levels and albumin blood levels also trended in the desirable direction after the three-month motivational interviewing intervention. These positive changes could be due to adherence behaviors of skipped and shortened treatments being relatively easier to impact with motivational interviewing due to the very nature of the improved quality, frequency, and proximity of staff-patient interaction to these treatment outcomes. For example, when a patient requested to shorten a dialysis treatment, the dialysis staff may have used motivational interviewing in a collaborative spirit to help the patient maximize dialysis therapy to motivate and discuss the desired behavior of remaining on the dialysis machine. Likewise, when a patient missed a dialysis treatment, the dialysis staff likely communicated about the missed treatment and possible solutions with the patient using motivational interviewing within a day or two of the missed treatment. Motivational interviewing may have fostered improved patient-staff communication and relationships, which encouraged discussion of possible solutions to shortening or missing dialysis treatments.

Improvements in diet and medication adherence as measured by phosphorous and albumin levels may also be due to enhanced communication between patients and staff from motivational interviewing. Making an impact on adherence to medications and diet is challenging, and reasons for abnormalities in these measures are multifactorial (Saran et al., 2003). In addition, the dialysis center's practice patterns in managing patients with abnormal phosphorus and albumin levels typically involved the dietitian reviewing laboratory values with the patient only monthly. In spite of these fairly infrequent interactions, motivational interviewing conversations specifically related to changing medication and diet behaviors appeared to have improved adherence.

Motivational interviewing interventions had little impact on IDWG in this pilot study. In a review of psychological interventions to improve IDWG in patients receiving hemodialysis, only one study used a motivational interviewing intervention, and it was used in combination with cognitive-behavioral therapy in an attempt to improved IDWG (Fisher et al., 2006). Using a case series approach, the combination intervention was administered (up to 12 times) to five adult patients being treated with hemodialysis. Three patients' reduced their mean IDWG and the frequency with which they gained greater than 3% of their dry weight. Only two of these three patients maintained this improvement in IDWG adherence during the six-month follow up. Two patients were lost to follow up at three months, and one was lost at six months. Four of the five patients reported the combined intervention to be acceptable. It is hypothesized that using motivational interviewing to improve fluid intake adherence may motivate patients to change their behavior, but the constant thirst experienced by patients in the context of having fluids available to them in their environment may make it difficult to achieve fluid intake goals. Other confounding variables, such as salt intake, may have impacted IDWG. These possible confounders should be evaluated in a larger, fully powered study.

Adherence to dialysis regimens is a complex and seemingly never-ending process for patients. Though motivational interviewing seeks to enhance patients' motivation to change behavior, other psychological processes have been tested to improve adherence behavior with mixed results (Sharp, Wild, Gumley, & Deighan, 2005). Using an RCT design, Sharp and colleagues (2005) used a four-week cognitive behavioral therapy intervention administered in a group format that sought to change attitudes and beliefs to improve adherence behavior with 56 adult patients receiving hemodialysis. The researchers found no statistically significant difference between groups' mean IDWG at the end of the four-week intervention (p > 0.05), which is consistent with current study findings. They did find a statistically significant difference between groups in IDWG at eight weeks (p < 0.001).

Use of dialysis staff members to administer the motivational interviewing intervention provides support for its use in the clinical setting. However, this may also be seen as a study limitation. Though staff members were trained to a minimum competence level on the use of motivational interviewing techniques and provided with systematic coaching sessions by the motivational interviewing expert, there was likely variation in competence level when using motivational interviewing. Future studies could compare the effectiveness of motivational interviewing when delivered by trained researchers versus dialysis staff.

Additional study limitations include a pre-test/post-test design, which limits the ability to determine causality, a lack of power that limits the ability to detect a difference if it exists; use of a single center, which limits generalizability; and possible selection bias in that those who did not agree to participate may have had different adherence behaviors than those who did agree to participate. There is also the possibility of the Hawthorne effect, where participants may have altered their behavior spontaneously--not as a result of the motivational interviewing intervention--to please researchers. Finally, the KDOQI guidelines to measure outcomes lack specificity to adherence. Self-report adherence measures continue to be developed and tested. These measures may expand future sensitivity and specificity in measuring adherence to the dialysis regimen (Kim, Evangelista, Phillips, Pavlish, & Kopple, 2010).

Conclusion

This pilot pre-test/post-test study explored the impact and feasibility of a staff-delivered motivational interviewing intervention on adherence behaviors in adult patients receiving hemodialysis. Motivational interviewing shows promise as an intervention to improve adherence in adult patients receiving hemodialysis. Four of the five adherence outcomes showed improvement after the three-month staff-delivered motivational interviewing intervention. IDWG was less favorably influenced by this approach. Staff members and patients generally found this communication approach acceptable. Future studies should explore the effectiveness of this approach in a fully powered study using a randomized controlled trial design.

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Cynthia L. Russell, PhD, RN, ACNS-BC, is an Associate Professor, University of Missouri, Sinclair School of Nursing, Columbia, MO, and a member of ANNA's Central Missouri Chapter. She may be contacted via e-mail at russellc@missouri.edu

Nikole J. Cronk, PhD, is a Clinical Assistant Professor, Department of Family and Community Medicine, University of Missouri, Columbia, MO.

Michelle Herron, RN, is a Nurse Manager, Moberly, MO.

Norma Knowles, MSW, LCSW, NSW-C, is a Social Worker, Dialysis Clinics, Inc., Columbia, MO.

Michelle L. Matteson RN, CS, FNP/GNP, is a Gastroenterology/Hepatology Nurse Practitioner and Doctoral Student, Sinclair School of Nursing, University of Missouri, Columbia, MO.

Leanne Peace, MSW, LCSW,, MHA, is Director, Missouri Kidney Program, Columbia, MO.

Leonor Ponferrada, BSN, RN, CNN, is an Education Coordinator, Dialysis Clinic, Inc., and the University of Missouri School of Medicine, Columbia, MO, and a member of ANNA's Central Missouri Chapter.

Authors' Note: This research was supported by a grant from the American Nephrology Nurses' Association.

Statement of Disclosure: The authors reported no actual or potential conflict of interest in relation to this continuing nursing education article.
Table 1
Non-Adherence Outcome Parameters

Non-Adherence Measure                       Parameters

Missed treatments           Attendance at less than the prescribed
                            number of weekly dialysis treatments

Shortened treatments        Shortening a single prescribed dialysis
                            treatment by 10 minutes or greater

Interdialytic weight gain   Good: less than 2.0 kg

                            Moderate: 2.0 to 3.0 kg

                            Poor: greater than 3.0 kg
Biochemical Data

Serum phosphorus            Good: 3.5 to 5.5 mg/dL

                            Moderate: 2.0 to less than 3.5 mg/dL or
                            greater than 5.5 to 6.5 mg/dL

                            Poor: greater than 6.5 or less than 2.0
                            mg/dL

Serum albumin               Good: greater than 4.0 g/dL

                            Moderate: 3.0 to 4.0 g/dL

                            Poor: less than 3.0 g/dL

Table 2
Characteristics of the Sample at Baseline
(N = 19)

                                                        Total Sample
                   Characteristics                      (n =15)

Age M (SD)                                              66.41 (13.9)
Gender, n (%) (female)                                  10.00 (53)
Ethnicity, n (%) (Caucasian)                            13.00 (68)
Education level, n (%) (some high school/high school)   14.00 (74)
Employment (retired), n (%)                             10.00 (53)
Non-smoker, n (%)                                       15.00 (79)
Months on dialysis M (SD)                               56.13 (41.1)
Etiology of CKD-diabetes mellitus, n %                  10.00 (53)

Note: M = mean; SD = standard deviation.

Table 3
Motivational Interviewing Effectiveness
(N = 19)

                            Improved   Unchanged   Worsened
Adherence Measures           n (%)       n (%)      n (%)

Missed treatments            5 (26)     13 (68)     1 (6)
Shortened treatments         9 (47)      6 (27)     4 (21)
Interdialytic weight gain    2 (11)     12 (63)     5 (26)
Phosphorous                  6 (32)      9 (47)     4 (21)
Albumin                      4 (21)     14 (73)     1 (6)

Table 4
Motivational Interviewing Effectiveness (N = 19)

                               Pre-Intervention   Post-Intervention
Adherence Measures                  n (%)              n (%)

Missed treatments

0 times                            14 (74)             18 (95)
1 time                              2 (11)              1 (5)
2 times                             2 (11)              0
7 times                             1 (4)               0

Shortened treatments

0 times                             6 (32)              9 (47)
1 time                              5 (26)              6 (31)
2 times                             5 (26)              2 (11)
3 times                             1 (5)               2 (11)
4 times                             2 (11)              0

Interdialytic weight gain

Good: less than 2.0 kg              6 (32)              5 (26)
Moderate: 2.0-3.0 k                 9 (47)              7 (37)
Poor: greater than 3.0 kg           4 (21)              7 (37)

Phosphorous mg/dL

Good: 3.5 to 5.5 mg/dL              4 (21)              4 (21)
Moderate: 2.0 to less than          9 (47)             12 (63)
  3.5 mg/dL or greater than
  5.5 to 6.5 mg/dL
Poor: greater than 6.5 mg/dL        6 (32)              3 (16)
  or less than 2.0 mg/dL

Albumin g/dL

Good: greater than 4.0 g/dL         4 (21)              7 (37)
Moderate: 3.0 to 4.0 g/dL          15 (79)             12 (63)
Poor: less than 3.0 g/dL            0                   0
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Title Annotation:Continuing Nursing Education
Author:Russell, Cynthia L.; Cronk, Nikole J.; Herron, Michelle; Knowles, Norma; Matteson, Michelle L.; Peac
Publication:Nephrology Nursing Journal
Article Type:Report
Geographic Code:1USA
Date:May 1, 2011
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