Rediscovering Motivational Interviewing Spirit: Working with Patients Receiving Hemodialysis in the HOPE Consortium Trial.

Motivational interviewing (MI) is an evidence-based approach which health care providers can use with and for a broad variety of patients in medical settings.1,2 MI is a particular way of interacting with patients (and others) that emphasizes respect and autonomy. MI includes both techniques and spirit (the latter referring to the provider's way of being1,2 and interpersonal approach interacting with the patient). There are numerous MI techniques, including the provider reflecting (i.e., stating back) the patient's thoughts and feelings, as well as affirming the patient's efforts, among others. MI spirit focuses on partnership, acceptance of the patient and their values and perspectives, and compassion, while evoking from the patient their beliefs, ideas, and preferences. Evocation can involve the patient's ambivalence about the consistency of their actions with their values and hopes. As such, listening by the provider is a central component of MI. Both techniques and spirit are essential to the fidelity of MI and positive outcomes.1,2 The literature on MI with and for people with kidney failure focuses on its potential to motivate and improve adherence to lifestyle changes.3–5 Indeed, use of MI has been found to enhance adherence and well-being in patients with kidney failure for many outcomes.6 Existing literature, however, has focused almost exclusively on application of techniques to direct patients' behavior change toward adherence with medical recommendations. Important to work with patients with kidney failure (and others) and in keeping with Martino3 (2011), is the person-centered side of MI, specifically its “style or spirit of being with patients… rather than a mere application of techniques” (p. 78). This article summarizes interventionists' experiences and reflections about incorporating MI into Pain Coping Skills Training (PCST) and its use with kidney failure patients generally.7 PCST was the active treatment in the HOPE (i.e., HOPE Consortium Trial to Reduce Pain and Opioid Use in Hemodialysis) multisite clinical trial to test its effectiveness at reducing pain interference and enhancing quality of life for patients receiving dialysis.7 PCST, including MI, was implemented in up to 12 individual sessions with patients by six interventionists with Master's degrees in either Social Work or Mental Health Counseling, with a range of 5–25 years of clinical experience. Training on MI was provided, complementing their prior clinical training and experience. Adherence to the PCST protocol was monitored; monthly supervision on MI was provided throughout the trial. Interventionists partnered with onsite research coordinators to facilitate visits, with occasional interactions with dialysis unit nurses and physicians. The focus was on relationship-building and respect for patient autonomy, which the interventionists regarded as an essential first step and foundational platform for MI, after which a process of setting behavior change goals could begin. A secondary priority was addressing adherence to medical regimens. This article is a reintroduction and reminder of the importance of MI spirit in interactions with patients with kidney failure to enhance patient engagement and goal alignment. Implementation of MI in health care is often conceptualized as a defined set of techniques, methods, and skills, toward the purpose of motivating and facilitating patient behavior change2 and/or behavior maintenance. In its inception, however, MI was designed as an approach to patient interactions, one which builds on the relationship and spirit of MI, blended with purposeful skills and methods.1,6 Interventionists used MI skills to facilitate behavior change by mutual goal-setting, identifying action steps toward goals and using decisional balance (a way of exploring ambivalence about change by weighing pros and cons of maintaining the status quo versus enacting changes). MI skills were most commonly used in session four of the PCST protocol, in which specific focus was on understanding patient values and establishing patient-set health goals. Interventionists typically deployed MI skills such as simple and complex reflections (i.e., statements and not questions that mirror what the patient says), acknowledging patient ambivalence about change, and following and guiding (but not directing or prescribing). Ultimately, choices about change goals were identified and set by the patient. MI spirit, however, was most treasured by interventionists and patients alike, as it offered a framework which scaffolded all other health care processes through listening and honoring patient autonomy. As interventionists employed active listening, reflective curiosity, and belief in the patient as the expert on their own life, patients in turn felt freed and empowered to enact behavior change which aligned with their own self-set goals for health and wellness. Of note, these goals sometimes differed from (but did not per se contradict) the prescribed behavior change recommendations from the nephrology team. The spirit of MI was a crucial beacon, guiding interventionists in the complexities of working with patients who are in dire medical circumstances, adhering to a structured clinical research protocol, and serving alongside nephrologists and other providers. For the nephrology care team, MI spirit is invaluable because it allows for a meeting of the minds with patients, balancing the promotion of kidney health with the spirit of patient empowerment, thus best serving both patients and practitioners. While adopting a spirit-based approach may seem impossible in busy clinical settings, in the end, it may actually save time and surely will strengthen patient-provider relationship and rapport. Interventionists found MI spirit helpful in instances in which patients were not following medical guidance (e.g., exercise, attendance at hemodialysis appointments, fluid or dietary intake guidelines), to explore both patient experience of health care and personal choices. Respect for patients and their autonomy was the first and primary consideration, thus avoiding criticism, guilt induction, and shaming. With both MI spirit and skills, interventionists maintained a stance of listening and guiding, while honoring patient autonomy. The life-threatening and life-changing nature of kidney failure can evoke strong emotionality in patients, often in the form of fear, anxiety, worry, or grief. Interventionists routinely noticed, in partnership with patients, a significant shift and decrease in their ability to manage day-to-day activities and maintain their health to comfortable and prior levels. Yet the medical reality is that hemodialysis is a consequential threat to emotional functioning and quality of life.8 The stakes are so high to maintain hemodialysis that the fixing reflex1 (described in MI as the tendency to offer advice and provide solutions) may understandably be elicited in providers because they realize the gravity of the patient's situation and the need for medical assistance and adherence to sustain life. This intersection can lead to a situation in which patients seem to be frozen or resistant, working with providers who are pushing for radical change and quick action. When patients and providers are not on the same page or same pace, MI can be a solution and may even be lifesaving. In a hemodialysis setting, strict adherence to the dialysis regimen is emphasized in an effort to maximize health and longevity; this lens can inspire a directive approach with patients. The strategy of telling people what to do or even what is in their best interest is ultimately less effective than a meaningful conversation that grows first and foremost from the patients' perspective and includes time and space for both parties to each speak and be heard. The expertise of the provider is critically important, of course, but must be balanced with respect for the patient's autonomy and authority to make their own decisions. Many of the trial participants reported a sense of powerlessness to manage and control day-to-day details of their life. In addition to contending with numerous health issues, they frequently reported not having enough opportunity to collaborate with their health care providers in decision-making about care plans and related treatment choices. As a result, they felt isolated and unsupported, perceptions that likely inadvertently exacerbated their symptoms and contributed to diminished overall quality of life. Both MI spirit and techniques1,9 are conceptually important to positive outcomes, particularly patient empowerment. Approaching and interacting with patients with MI, focusing on spirit and incorporating motivational interactions10 (very brief verbal exchanges with patients that are consistent with MI spirit) may be especially relevant for people being treated with dialysis. With MI, however, patients often found they identified the disparity between their personal values and current day-to-day behavior and consequently began to outline and enact a change plan that contributed to improved wellness overall. In summary, we stress the importance of spirit above technique with MI and motivational interactions1,10 in caring for patients with kidney failure. The flexible spirit of MI is novel and unique for this patient population and a valuable contrast to routine care in the hemodialysis medical setting. In addition to offering the known benefit to enhance adherence,6 MI spirit serves as a platform to develop rapport and relationship with the patient, building engagement and alliance. Jumping directly to MI techniques risks motivation for change seemingly prescribed by the provider. Clinicians caring for patients with kidney failure who embody the spirit of MI offer benefits that serve both patients and providers by helping both parties understand and trust one another and develop mutually agreed-upon goals. This collaborative effort brings together the expertise of providers with the empowered decision-making of patients undergoing hemodialysis and living with kidney failure.