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Patient empowerment and motivational interviewing: engaging patients to self-manage their own care.

Patients on dialysis are subjected to an ongoing onslaught of therapies and lifestyle changes that affect their psychological and psychosocial well-being. Patients are asked to make daily decisions about adhering to scheduled appointments, taking prescribed medicine, limiting the intake of fluid and certain foods, and managing the symptoms of chronic kidney disease (CKD) and other comorbidities. The challenges associated with living with CKD are significant and may contribute to patients feeling that they have lost control of their lives (see Table 1) (Bodenheimer, Lorig, Holman, & Grumbach, 2002; Curtin, Mapes, Petillo, & Oberley, 2002; Schatell & Witten, 2005).

Nurses and other members of the nephrology team have traditionally focused educational efforts on providing patients with the knowledge needed to comply with the prescribed treatment regimen. However, studies have consistently shown that patients cannot be forced to follow a lifestyle that is decided by others. Patient empowerment and self-management are therefore crucial to ensure that patients know they are still in control of their lives and are motivated to become engaged partners with nurses and other members of their nephrology healthcare team (Tsay & Hung, 2004). This article explores the importance of empowering patients on dialysis, including application of patient-centered motivational interviewing techniques to engage patients to internalize goals and accept the responsibility for self-management.

Autonomy, Hope, Engagement, and Empowerment in Patients on Dialysis

Patients' perceptions of hope, autonomy, and control over their own lives and illnesses may be fostered by empowering them to become involved in helping to manage their care. Patient empowerment is based on the tenets of self-determination theory, which states that individuals are naturally motivated to improve their own well being. This theory predicts improved outcomes among patients who approach the regulation of their own health from the perspective of autonomous self-regulation, competence, control, and self-determination. The theory has been consistently supported by study results showing that patients are much more likely to adhere to recommended therapeutic approaches if they have internalized the need for a behavioral change and value it personally than if others try to force them to behave in a way that is contrary to their nature (Williams, 2008).

The need for engaged, empowered, and self-managing patients is highlighted by the fact that patients spend 92% (hemodialysis) to 99.8% (peritoneal dialysis) of their time outside the confines of the dialysis facility. Self-management is therefore inherently necessary to ensure improved outcomes (Schatell & Witten, 2005).

Self-determination, autonomy, and empowerment have also been cited as key components for success among long-term survivors on dialysis. An exemplary investigation conducted semi-structured interviews with a group of patients who had been on dialysis for a mean of 21 years (range of 16 to 31 years). Patients consistently stated that the key to their success in living a long and healthy life on dialysis was the transformation into comprehensive, active, self-managers of their disease, its treatment, and its manifestations. Although their sense of self was being challenged, they retained the need for controlling their lives. As one patient stated, "You know when you are put in a category of a patient, whatever this is, chronic illness, you are seen by society in a certain way and you are put in a place with its own rules. I want to defy those rules, you know. I want to prove to the world that because my kidneys failed doesn't mean that it is the end of me" (Curtin et al., 2002, p. 616).

Patients' willingness to become involved in managing their own care is closely tied to their abilities to set goals and to their hopes for the future. Many studies have shown that hope is a vital determinant of positive outcome and that hope is necessary for adjusting to and living with CKD. In a cross-sectional analysis of 103 patients on dialysis, multiple regression analyses were applied to determine whether hope could predict adjustment to CKD. The study assessed patient-reported hope (using the Trait Hope Scale), anxiety and depression (using the Hospital Anxiety and Depression Scale), and quality of life (using the Kidney Disease Quality of Life-36 questionnaire) (Billington, Simpson, Unwin, Bray, & Giles, 2008). After adjustment for demographic and illness-related factors, hope was found to be a significant factor that predicted interpatient variations in anxiety, depression, and physical and mental health quality of life. Patients with higher levels of hope were less likely to be anxious or depressed and more likely to have improved physical and mental health quality of life. Overall, hope correlated positively with patient perceptions of quality of life, including improved physical (P 0.05) and mental health (P [less than or equal to] 0.001). Conversely, hope was associated with lower levels of depression (P [less than or equal to] 0.001) and anxiety (P [less than or equal to] 0.001). The authors observed that hope may lessen the emotional impact of CKD and its treatment, thereby empowering individuals to reframe threats as challenges (Billington et al., 2008).

Several studies have demonstrated the links among patient empowerment, autonomy, and improved outcomes. The Dialysis Morbidity and Mortality Study Wave 2 analyzed responses from 42,418 patients who were new to dialysis to determine how patient involvement in the dialysis modality selection process affected survival and the likelihood of transplantation. Autonomy in the decision-making process was determined using patient-reported impressions of how they participated in the initial decision-making process, described as a) "I took the lead in selecting my treatment," b) "The medical team took the lead in selecting my treatment," or c) "The medical team and I contributed equally to selecting my treatment." Based on the responses, the decision-making process was categorized as being patient-led, patient-and-team led, or team-led (Stack & Martin, 2005).

Overall, 26.3% of patients reported a patient-led dialysis modality decision, 35.6% reported a team-led decision, and 38.1% reported a patient-and-team-led decision. The impact of patient empowerment in the decision-making process was demonstrated by Cox adjusted survival curves over a 4-year follow-up period. Patient empowerment led to a statistically significant decrease in the risk for mortality. This analysis found a 39% decrease in the risk for mortality among those in the patient-led group, and a 24% lower risk in the patient-and-team-led group when compared with patients whose choice of dialysis modality was made solely by the healthcare team (P< 0.001). A multivariate adjusted model showed that patients who participated in the initial decision-making process had a 44% to 53% increased chance of renal transplantation compared with those whose dialysis modality was solely chosen by the healthcare team (P < 0.01 to P [less than or equal to] 0.05) (Stack & Martin, 2005).

Similarly, a multicenter analysis of 160 patients on hemodialysis examined the relationships among selfcare/self-efficacy, depression, and quality of life. This cross-sectional analysis collected patient-reported data using three validated patient questionnaires: the Strategies Used by People to Promote Health Survey, the Geriatric Depression Scale, and the Quality of Life Index. Results showed that patients who perceived higher levels of self-care/self-efficacy were more likely to have a higher level of satisfaction with life, and that patients' perceptions of self-care/self-efficacy explained 47.5% of the variance in quality of life among the patient population (P < 0.001) (Tsay & Healstead, 2002).

A randomized controlled study of 50 patients on dialysis demonstrated the potential benefits of a concentrated, nurse-coordinated program to encourage patient self-management and empowerment. Subjects in the control and experimental groups received identical packets of information on CKD, potential therapies, coping strategies, and other components of care. In addition, the experimental group participated in twelve one-on-one consulting sessions in which nurses fostered empowerment by helping patients develop self-management skills, including goal setting, problem solving, stress management, coping techniques, social support, and motivation. A patient-led behavioral change program encouraged patient identification of problem areas that could be addressed through self-management, exploration of emotions, development of goals and strategies to achieve these goals, and a self-care plan for behavioral change and stress management (Tsay & Hung, 2004). Patient-reported outcomes were assessed through several validated survey instruments. Patients' perceptions of their own empowerment was measured using the Empowerment Scale, which included subscales on managing the psychosocial aspects of disease, assessment of dissatisfaction and readiness to change, and how goals were set and achieved. The Strategies Used by People to Promote Health Scale was used to assess patients' perceptions of self-care and self-efficacy. Finally, depression was assessed using the Beck Depression Inventory, a scale that allows patients to report on longitudinal changes in distress and complaints.

Data for both groups were collected at baseline and 6 weeks after completion of the intervention in the experimental group. Results indicated significant improvements in empowerment (P < 0.001), self-care and self-efficacy (P = 0.002), and depression (P = 0.003) among patients in the experimental group compared with those in the control group. The authors indicate that clinicians who care for patients on dialysis should consider patient empowerment as an essential component of care. They further suggest that a patient's degree of empowerment should be assessed like any other component of therapy, and nurses should be trained to consult with patients to refine self-management and empowerment skills (Tsay & Hung, 2004).

Engaging Patients in Their Own Care-Application of Motivational Interviewing Techniques

Patients are becoming increasingly involved in managing their own care, and patient groups have offered tips to medical professionals on how to encourage patient engagement (see Table 2) (Hartwell, 2006). One practical method of fostering patient engagement and empowerment that incorporates the spirit of these patient-generated suggestions is the motivational interviewing technique. The concept of motivational interviewing was initially developed in the 1980s to improve behavior in patients with substance abuse. Subsequent studies in patients with a variety of chronic illnesses (such as diabetes, cardiovascular disease, hypertension, hyperlipidemia, asthma) demonstrated that motivational interviewing may help improve patient outcomes, including psychological, physiological, and life-style change components of care (Knight, McGowan, Dickens, & Bundy, 2006; Levensky, Forcehimes, O'Donohue, & Beitz, 2007). The presence of many of these comorbidities in patients on dialysis has generated tremendous interest in the use of motivational interviewing in patients.

Motivational interviewing is a counseling approach that effectively engages patients and healthcare professionals in a collaborative partnership centered on patient goal setting and self-management. Using the motivational interviewing model, the healthcare professional helps patients express their reasons for and against behavioral changes, how current health behavior may conflict with personal health goals, and how current behavior or health status affects the ability to achieve these goals. It also helps patients address and overcome their ambivalence to change, that is, simultaneous contradictory attitudes about whether or not to change behavior (for example, "I should stop smoking, but I enjoy smoking") (Sevick et al., 2007).

Core Counseling Principles

There are several key components of motivational interviewing that can be used to successfully incorporate this process into clinical practice (see Table 3). Note that while the examples outlined below focus on nurse application of motivational interviewing, all members of the nephrology team can apply the same techniques. Motivational interviewing has four core counseling principles.

Express empathy for the challenges faced by patients. Empathy involves placing yourself in the patient's position and acknowledging the topic being discussed as though you are looking through the patient's eyes. Empathy requires the nurse to provide respectful, non-judgmental responses to the patient's statements and opinions, thereby encouraging the development of a collaborative relationship (Levensky et al., 2007).

Develop a discrepancy. Developing a discrepancy involves increasing a patient's awareness of the discrepancy between his or her current behavior and self-expressed goals, interests, and values. Development of a discrepancy between goals and behavior is crucial for motivating patients to internalize the need for action while accepting the responsibility for self-change. It is important that the nurse does not identify these discrepancies for the patient. Self-realization requires that the patient be guided to recognize the discrepancy between current behavior and his or her own goals, interests, and values, while exploring methods for incrementally and willfully changing his or her own behavior (Levensky et al., 2007).

Roll with resistance. Resistance is a signal that the patient is ambivalent about change and a sign that the nurse should respond differently to ensure that the lines of communication remain open. Rolling with resistance is a technique of avoiding nurse-patient conflict while keeping the patient engaged in the process. To apply this technique, the nurse remains non-judgmental regarding the patient's actions, avoids argument, and encourages the patient to keep talking and stay involved. For example, instead of arguing with a patient or becoming confrontational if a patient does not take prescribed medications, the nurse invites--rather than imposes--new perspectives and allows the patient to be the primary source of answers and solutions (Levensky et al., 2007).

Support self-efficacy. To support self-efficacy, the nurse should provide ongoing encouragement and foster the belief that the patient is able to perform in a certain manner to achieve self-identified goals. The nurse should also provide ongoing positive reinforcement to support the patient's ability to choose and carry out a plan that can change behavior and improve outcomes. Support for self-efficacy provides the patient with a sense of empowerment by demonstrating that the patient is the member of the team who controls change (Levensky et al., 2007).

Motivational Interviewing Therapeutic Skills

To carry out the four principles outlined above, motivational interviewing employs several basic therapeutic skills: resist the righting reflex, use reflective listening, ask open-ended questions, ask-provide-ask, and affirm and summarize.

Resist the "righting reflex." The righting reflex is the natural tendency of the nurse to fix a patient's problems by imposing solutions (Levensky et al., 2007). In contrast, motivational interviewing encourages patient engagement by eliciting patients' reasons for change, encouraging them to develop ideas on how to make changes in their own behaviors, and helping them make informed choices. Thus, the spirit of the motivational interviewing model is to establish a partnership in which the nurse provides empathy and support while helping patients formulate and internalize their own reasons for change (Bodenheimer et al., 2002; Schatell & Witten, 2005).

Use reflective listening. Reflective listening involves responding to a patient by concisely restating the patient's own statements. The purposes of reflective listening are to ensure that the nurse understands what the patient means, while simultaneously diminishing the patient's resistance to change. In a typical scenario in which motivational interviewing techniques are not applied, a nurse may try to persuade a patient to change behavior. In contrast, with reflective listening, the nurse restates the statements that the patient makes about a challenge he or she is facing and the patient's desire for change. This is then followed by a non-judgmental question, thereby eliciting additional statements from the patient about the need for change and how the patient may be able to take the lead in eliciting that change (Levensky et al., 2007).

Ask open-ended questions. In a motivational interview, the patient should do most of the talking. To foster a patient-centered dialogue, the nurse should avoid questions that can be answered with brief yes or no answers (Levensky et al., 2007). For example, the question "Do you know everything you need to know about controlling your anemia?" could easily be answered with a brief yes or no answer that could limit further discussion. In contrast, a question such as, "What are the worst things that might happen if you do not receive your medications for anemia?" can help the nurse gauge knowledge while helping the patient express his or her own short- and long-term goals for managing a specific comorbidity.

Ask-provide-ask. Patient-nurse inter-actions often require the nurse to provide specific information about a medical condition or therapeutic intervention. It is important that this information is provided to patients in a way that is consistent with the motivational interviewing technique. One way to accomplish this goal is by using the ask-provide-ask approach. First, the nurse asks the patient what the patient knows about the topic being discussed. For example, "Tell me what you already know about anemia and how it is managed." If the patient appears to need additional information, the next step in the process is to ask the patient for permission to provide that information. For example, the nurse could ask, "I would like to share some more information with you about what anemia is and how it can be effectively managed. Would that be okay with you?" The final step is for the nurse to ask the patient to discuss his or her thoughts about the information provided, and respond to the patient using reflective listening and open-ended questions. An example question for this final "ask" stage could be "What are your reactions to what I have told you about how anemia may affect your quality of life?" (Levensky et al., 2007).

Affirm and summarize. The final skills in motivational interviewing are to affirm and summarize the information--both of which can be applied throughout the conversation. Affirming involves the nurse making statements that support, encourage, and recognize the patient's difficulties. Affirmation statements can be as straightforward as saying, "It's great that you have been able to be at all your dialysis sessions this month." Affirmation supports patient's self-efficacy, builds rapport, and reinforces the effort the patient is making. Summary statements link and rein force the information that was discussed with the patient, including the patient's statements on his or her desire to change, the important points that have been raised, and how the nurse will help monitor the patient-expressed plan for change (Levensky et al., 2007).

Conclusions

Nurses typically spend a significant amount of time trying to convince patients to change potentially harmful behaviors. Data have consistently shown that behavior cannot be successfully modified unless patients set their own goals and internalize the need for change. Motivational interviewing respects patient self-determination, acknowledges patient autonomy, and recognizes that it is the patient who must decide whether and how to change behaviors. It can be incorporated into normal conversation with the patient. Use of this technique can help engage and empower patients, thereby establishing a nurse-patient partnership that can help patients achieve their personal goals.

Acknowledgments: The author would like to thank Michael Josbena, RPh, MS, for providing medical writing assistance with funding provided by Amgen, Inc.

Note: This article is supported by a financial grant flora Amgen. The manuscript has undergone peer review. The information does not necessarily reflect the opinions of ANNA or the sponsor.

References

Billington, E., Simpson, J., Unwin, J., Bray, D., & Giles, D. (2008). Does hope predict adjustment to end-stage renal failure and consequent dialysis? British Journal of Health Psychology, 13, 683-699.

Bodenheimer, T., Lorig, K., Holman, H., & Grumbach, K. (2002). Patient self-management of chronic disease in primary care. Journal of the American Medical Association, 288(19), 2469-2475.

Curtin, R.B., Mapes, D., Petillo, M., & Oberley E. (2002). Long-term dialysis survivors: A transformational experience. Qualitative Health Research, 12, 609-624.

Hartwell, L. (2006). Promoting patient participation in the dialysis setting. Presented at the 4th Annual New Jersey CRN Renal Nutritional Conference, Princeton, NJ.

Knight, K.M., McGowan, L., Dickens, C., & Bundy, C. (2006). A systematic review of motivational interviewing in physical health care settings. British Journal of Health Psychology, 11, 319-332.

Levensky, E.R., Forcehimes, A., O'Donohue, W.T., & Beitz, K. (2007). Motivational interviewing: An evidence-based approach to counseling helps patients follow treatment recommendations. American Journal of Nursing, 107(10), 50-58.

Schatell, D., & Witten, B. (2005). Dialysis patient empowerment: What, why and how. Nephrology News & Issues, 19(9), 37-44.

Sevick, M.A., Trauth, J.M., Ling, B.S., Anderson, R.T., Piatt, G.A., Kilbourne, A.M., et al. (2007). Patients with complex chronic diseases: Perspectives on supporting self-management. Journal of General Internal Medicine, 22(Suppl. 3), 438-444.

Stack, A.G., & Martin, D.R. (2005). Association of patient autonomy with increased transplantation and survival among new dialysis patients in the United States. American Journal of Kidney Diseases, 45(4), 730-742.

Tsay, S.L., & Healstad, M. (2002). Self-care self-efficacy, depression, and quality of life among patients receiving hemodialysis in Taiwan. International Journal of Nursing Studies, 39(3), 245-251.

Tsay, S.L., & Hung, L.O. (2004). Empowerment of patients with endstage renal disease--A randomized controlled trial. International Journal of Nursing Studies, 47(1), 59-65.

Williams, G.C. (2008). The importance of self-determination in CKD. Nephrology News & Issues, 22(10), 34.

Patrick, McCarley, MSN, RN, ACNP, CNN, is an Advanced Practice Nurse, Diablo Nephrology Medical Group, Walnut Creek, CA. She is a member of the Northern California Chapter of ANNA and an Editorial Board member of the Nephrology Nursing Journal.
Table 1

Sample Challenges That May Contribute to Patients Feeling That They
Have Lost of Control of Their Lives

* Maintaining meaningful life roles (such as job, family, friends)

* Coping with fear, anger, frustration, sadness of a chronic condition

* Accepting disruption in routines

* Confronting their own mortality

* Ensuring adequate dialysis care

* Adhering to described therapies

* Adjusting to lifestyle changes

Sources: Bodenheimer et al., 2002;
Curtin et al., 2002; Schatell & Witten, 2005.

Table 2

Tips from Patients on Encouraging Patient Engagement

*  Provide a vision of the future

*  Add some fun and variety to the patient's routine

*  Engage the patient in providing input to the healthcare plan

*  Assist in developing goals and challenges with the patient,
not for the patient

*  Develop measurements to illustrate improvement

*  Promote social interaction among patients

*  Ask questions and listen to the patient's feedback

*  Provide encouragement

Source: Hartwell, 2006.

Table 3

Core Counseling Principles and Motivational Interviewing
Therapeutic Skills

* Express empathy for the challenges faced by patients

* Develop a discrepancy between patient goals and behaviors

* Roll with resistance

* Support self-efficacy

* Resist the "righting reflex"

* Use reflective listening

* Ask open-ended questions

* Use the ask-provide-ask approach to provide information

* Affirm patient's opinions and progress

* Summarize main points and goals

Source: Adapted from Levensky et al., 2007.
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Title Annotation:Sponsored Educational Supplement: AMGEN[R]
Author:McCarley, Patricia
Publication:Nephrology Nursing Journal
Geographic Code:1USA
Date:Jul 1, 2009
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