practice 248 journal of renal nursing vol 5 no 5 September 2013 © 2 01 3 M A H ea lt h ca re L td 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 develo.

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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.

2. 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

3. 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

4. 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;

6. 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

7. 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’

8. 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

10. 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

11. 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

12. 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

13. 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’

14. 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

15. 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

16. 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:

17. 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’,

18. ‘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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