Enhancing Self-Care Management
of Interdialytic Fluid Weight Gain
in Patients on Hemodialysis: A Pilot
Study Using Motivational Interviewing
Stacy Crown
Janet A. Vogel
Christina Hurlock-Chorostecki
ealthcare professionals strug-
H
gle to support self-care by
those who require hemodialy-
sis as renal replacement thera-
py. In particular, managing fluid con-
sumption based on the patient’s body
needs and ability to eliminate fluid is
challenging (Iborra-Molto, Lopez-
Roig, & Pastor-Mira, 2012). Patients
on dialysis are counseled to limit their
interdialytic (ID) fluid weight gain
(Daugirdas, Blake, & Ing, 2015;
Kahraman et al., 2015) to reduce
uncomfortable symptoms, such as
edema and shortness of breath, as
well as reduce the progression of left
ventricular hypertrophy, a risk factor
leading to cardiac death (Cader,
Ibrahim, Paul, Gafor, & Mohd, 2014).
Adhering to a restricted ID fluid
intake promotes cardiovascular
health, increases patient comfort, and
ensures the uneventful, safe delivery
of dialysis (Movilli et al., 2013).
Dialysis treatments include the
decision of an appropriate dry weight
for each patient, and treatment ses-
sion parameters are based on achiev-
ing this target dry weight. However,
Stacy Crown, MN, NP, is a Nurse Practitioner,
Woodingford Lodge, Ontario, Canada. She com-
pleted this research project as an NP student.
Janet A. Vogel, BScN, RN, CNeph, is a Certified
Renal Nurse and Clinical Educator, the Renal and
Medicine Programs, London Health Sciences
Centre, London, Ontario, Canada.
Christina Hurlock-Chorostecki, PhD, NP, is
an Associate Professor, the Labatt Family School of
Nursing, Western University, London, Ontario,
Canada.
Statement of Disclosure: The authors reported
no actual or potential conflict of interest in rela-
tion to this continuing nursing education activity.
Note: The Learning Outcome, additional state-
ments of disclosure, and instructions for CNE
evaluation can be found on page 56.
Nephrology Nursing Journal January-February 2017
Continuing Nursing
Education
Copyright 2017 American Nephrology Nurses Association.
Crown, S., Vogel, J.A., & Hurlock-Chorostecki, C. (2017). Enhancing self-care manage-
ment of interdialytic fluid weight gain in patients on hemodialysis: A pilot study
using motivational interviewing. Nephrology Nursing Journal, 44(1), 49-55.
Patients receiving hemodialysis are challenged with restricting their fluid intake to
ensure appropriate interdialytic weight gains. While nurses endeavor to promote self-
care, the ability to manage fluid gain rests on the patient’s understanding and decision
to limit fluid intake. A mixed-methods pilot study was undertaken to determine if moti-
vational interviewing, a patient-centered, conversational, and collaborative approach to
stimulating behavior change and resolving ambivalence, enhances self-care fluid man-
agement. Participants felt that motivational interviewing was very helpful, although
findings suggest self-care fluid management requires a toolkit of interventions. Key moti-
vational interviewing actions for nurses are presented.
Key Words: Hemodialysis, motivational interviewing, interdialytic, self-care, fluid
management.
many patients are unwilling or unable cur that MI techniques are effective in
to self-manage their fluid restriction supporting health behavior change
(Iborra-Molto et al., 2012). In these sit- (Barnes & Ivezaj, 2015; Lundahl &
uations, those managing the dialysis Burke, 2009; Martins & McNeil,
treatment try to assist patients in 2009).
achieving their target dry weight by Miller and Rollnick (2013) ex-
adjusting the dialysis machine ultrafil- plain that the aim of MI is to encour-
tration (UF) rate to remove more age behavior change through collabo-
fluid. This high UF rate during dialysis rative exploration and resolution of
risks complications, such as prolonged the patient’s ambivalence. The ap-
painful muscle cramping, nausea, proach is based in empathy, where the
dizziness, and potentially, a hypoten- healthcare professional learns to
sive crisis (Kaze et al., 2012). expect and recognize ambivalence.
The ability to manage adequate Rather than provide a directive
levels of fluid rests solely on the approach, the healthcare professional
patient’s understanding and decision “rolls” with the patient’s resistance.
to limit fluid intake. Behaviors of man- The task of the healthcare professional
aging fluid intake can be influenced is to assist patients in exploring their
by the patient’s perceived barriers and ambivalence and offering direction as
the lack of motivation to address the they become motivated to change. All
barrier (Smith et al., 2010). Motiva- healthcare professionals can be train-
tional interviewing (MI), a coaching ed in techniques for the four principles
technique to better understand the of MI (see Table 1).
patient’s frame of reference, uses col- Miller and Rollnick (2013) assert
laboration and planning to strengthen behavior change is successful when
motivation and commitment to change the person’s beliefs and level of readi-
(Miller & Rollnick, 2013). Recent ness are understood, and the person
reviews of published MI research con- develops self-confidence. They sup-
Vol. 44, No. 1 49
Enhancing Self-Care Management of Interdialytic Fluid Weight Gain in Patients on Hemodialysis:
A Pilot Study Using Motivational Interviewing

Table 1
Principles and Actions of Motivational Interviewing

Principle Explanation Coaching Actions

Resist the righting The righting reflex is the natural tendency of
reflex healthcare professionals to tell their patients
what they believe is best and offer suggestions.
This reflex leads to frustration when the patient
does not adhere.
Understand and Motivation depends on the stage of change a
explore motivations person has reached (see Table 2).
Motivational interviewing is between two experts;
the patient and the healthcare professional.
Listen with empathy To listen with empathy is to acknowledge what
the person is saying through words and body
language. Try to see the world through the
patient’s eyes.
Empower the Give patients the power to make their own
person change. Understand relapse occurs.
• Avoid persuasion; instead of telling them, ask
for their desire to change.
• Engage in conversation and provide advice
only with patient permission.
• Create a non-judgmental atmosphere.
• Ask what motivates them and respect the
reason they present.
• Use open-ended questions. “If you tried to
reduce your fluid intake, what would that look
like for you?”
• Use the readiness ruler to determine your
actions to support motivation to change.
• Use reflective listening: reflect feelings and
thoughts you heard “It seems to me you are
saying…”
• Use active silence: provide opportunity for
patients to state their arguments against the
change.
• Be optimistic and hopeful.
• Encourage and support active involvement in
their care.
• Collaboratively create a personal action plan
to help the patient keep track of success.

Note: Rollnick, Miller, and Butler (2008) present four principles to guide the motivational interviewing process: resisting,
exploring, listening, and empowering. These are summarized here with actions.

port the use of the stages of change
to aid healthcare professionals in
understanding patient readiness. The
transtheoretical model of change
(Prochaska, Norcross, & DiClemente,
1994, 2013) provides characteristics of
five stages of change that can be used
with MI coaching (see Table 2). This
model states that change does not fol-
low a linear progression as a chart of
the model suggests. Therefore, it is
important for the healthcare profes-
sional to understand the stages of
change and employ the right process-
es in the right stage.
Russell et al. (2011) studied the
effectiveness of MI with patients on
hemodialysis and determined the
technique shows promise with a vari-
ety of health behaviors that are chal-
lenging for these patients. Hettema
and Hendricks (2010) suggest that MI
can be effective with patients who are
strongly resistant to change. How-
ever, it remains uncertain whether
this coaching technique (MI) is
advantageous for changing fluid man-
agement behaviors in patients on
hemodialysis. A pilot study was con-
ducted to explore the impact of
coaching fluid self-management using
MI techniques within the population
of patients on hemodialysis.
Study Design
A prospective, quasi-experimen-
tal, mixed-methods pilot study was
used to determine if interdialytic
weight gain changed in patients on
hemodialysis who received MI coach-
ing as an intervention. Participant
comments on their experiences were
logged, and each participant rated
their satisfaction with MI coaching.
The Intervention
MI coaching interventions were
provided by the research assistant (SC)
during the patient’s dialysis session. MI
conversations were held in a location
chosen by the patient. These conversa-
tions occurred primarily at the dialysis
station while the patient received dialy-
sis. Although most patients use head-
phones during dialysis, complete priva-
cy could not be assured. Each session
lasted 15 to 30 minutes, and included
MI techniques and documentation of a
log of weekly personal fluid intake
goals set by the participant. MI coach-
ing occurred three to four times over a
four-week period. Following each inter-
view, participant comments of their
experiences and perspectives were
recorded by the MI coach.
One MI research assistant (SC)
provided all coaching sessions. The
research assistant received MI coach-
ing education from a certified MI
trainer experienced in hemodialysis
( JV). The education included four
hours of training related to MI coach-
ing techniques and interdialytic fluid
weight gain risks and challenges. Self-

50 Nephrology Nursing Journal January-February 2017 Vol. 44, No. 1

 Table 2
The Stages of Change, Readiness Ruler, and Actions

Stage of Change Readiness Ruler Explanation Action

Pre- Low Confidence Person may not be aware that a • Provide informational pamphlets.
contemplation Not Important problem exists or has no intention • Ask patients to share how their illness
to act in next six months. impacts them and their family.
• Ask what it might take to get them from a
1
Reflects 1 to 3 on the readiness 3 to 4 on the readiness ruler.
2 ruler.
Contemplation 3 Person is aware that a problem • Listen with empathy.
exists and possibly sees a change • Provide an opportunity to discuss barriers.
4 in the next six months. • Encourage self-evaluation.
Preparation 5 Person engages in change talk • Listen for change talk.
expressing motivation to change: • Ask if you can help or what information is
6
“I want to,” “I hope to,” “I wonder needed.
7 how it would feel to…;” intends to • Encourage patient to develop a realistic
initiate change within 30 days. plan with achievable goals.
8
Action Person replaces behavior with • Listen to stories of obstacles and how
9 more positive behavior. There is they were overcome.
10 risk for relapse. • Praise positive steps and behaviors.
• Support reaffirmation of commitment to
change.
• Provide visual tools to post prominently.
Very Confident • Assist in revisiting goals and use of
Very Important support systems.

Maintenance Control of stimuli that elicit • Collaboratively develop a continuing care

behavior problems. plan that includes relapse prevention.
Relapse A return to negative behavior. • Work with patient to identify triggers.
• Identify personal strengths and
weaknesses related to triggers and
develop a plan to assist with control.

Note: Prochaska et al. (1994) present six stages of change. Four stages (precontemplation, contemplation, preparation, and
action) relate to readiness to change and are summarized here in conjunction with a readiness ruler.

directed learning using MI texts, pre-
sentations, and Internet-based educa-
tion furthered knowledge of the MI
principles. The core of the education
included the four guiding principles
of MI (see Table 1), the Stages of
Change Model by Prochaska and col-
leagues (1994, 2013) (see Table 2), use
of a readiness ruler tool (see Table 2)
to aid in identifying the patient’s
readiness to change, and a summary
log of weekly personal fluid intake
goals established by the participant.
Simulation exercises using dialysis-
specific fluid case scenarios provided
practical experience. MI coach com-
petence was established using a vali-
dated rating tool: the OnePass meas-
ure (McMaster & Resnicow, 2015).
Two team members (CHC and JV)
rated the research assistant’s perform-
ance as excellent (85%) on two dialy-
sis-specific scenarios.
Effective MI coaching requires
understanding a person’s readiness to
change and adjusting coaching
actions to motivate movement toward
action. The Stages of Change Model
(Prochaska et al., 1994, 2013) concep-
tualizes stages a person moves
through before taking action. A readi-
ness ruler is used to elicit conversa-
tion on confidence, ability, and will-
ingness to change (see Table 2).
Setting
The study was completed in a
nine-chair satellite dialysis unit locat-
ed at a community hospital in
Ontario, Canada. The unit accommo-
dates up to 36 ambulatory patients.
Registered nurses are the key care-
givers. Nephrology support for
patient care issues is available
through telephone consultation with a
nurse practitioner or nephrologist in
the acute hospital about 30 minutes
away. Patients who become unstable
are transferred to the acute hospital
dialysis unit.
Sample
A convenience sample of patients
attending dialysis at the selected dial-
ysis unit was recruited. Patients who
receive hemodialysis two or more
days per week and speak and under-

Nephrology Nursing Journal January-February 2017 Vol. 44, No. 1 51

Enhancing Self-Care Management of Interdialytic Fluid Weight Gain in Patients on Hemodialysis:
A Pilot Study Using Motivational Interviewing

Table 3
Demographic Characteristics
stand English were invited to partici-
pate in individual coaching sessions
Characteristics Total Sample (n = 18)
during their dialysis treatment. Those

Age M (SD) 55 (17.7)

enrolled in a weight loss program or
unable to use the dialysis unit weigh
scale were excluded. A sample size of Sex n (%) male 15 (83%)
Years on dialysis M (SD) 3.2 (3.4)
20 was sought based on a limited

Self-reported daily urine volume (range) 0 to 2000 mL (median 60 mL)

sample of participants (n = 36), feasi-
bility of providing the intervention in
a short timeframe, and the accepted Non urine producing n (%) 8 (47%)

Table 4
range of 10 to 40 participants in pilot

Average Interdialytic Fluid Weight Gain in Kilograms

studies in academic and research liter-
ature (Hertzog, 2008).

Participant ID Average Weight Average Weight Difference

number (n = 17) Gain (Time 1) Gain (Time 2) (1-2)
Data Collection
Data collected were participant
1 1.12 1.78 -0.67
demographics, ID fluid weight gains
2 2.44 2.01 0.43
at two time periods (before and dur-

3 1.81 1.61 0.20

ing the MI intervention), participant
comments, and a participant satisfac-
4 -0.05 -0.03 -0.02
tion survey. Ethical approval to con-
5 2.33 2.73 -0.39
duct the study was attained from the

7 2.27 3.24 -0.98

local university research ethics board
and the participating hospital.
Participants provided informed writ- 8 1.78 1.61 0.18
9 2.44 2.38 0.06
ten consent.

10 -0.27 -0.21 -0.06

11 1.26 1.78 -0.53
Results

12 1.67 0.95 0.72

13 -0.03 -0.90 0.88
Participant Characteristics
Eighteen participants were enrol-
led in the study. One participant was 14 0.60 0.63 -0.03
15 2.78 1.87 0.91
withdrawn due to illness requiring

16 -0.15 -0.16 0.01

hospitalization. All but one partici-

17
pant (94%) attended dialysis three
times a week (one patient attended 2.46 1.91 0.55
18 2.31 2.59 -0.28
two times per week). Demographic

Group average 1.46 1.40 0.06

characteristics are shown in Table 3.

Interdialytic Fluid Gain
Measures
The ID fluid gains were collected
on participants over two four-week
periods. Time #1 was the four weeks
before the MI intervention. Time #2
was the four weeks during the MI
intervention. Almost half (n = 8) of
the participants showed some reduc-
tion in their ID fluid weight gain, and
three had no change. The remainder
had an increased fluid weight gain
measured. The mean and standard
deviation of ID fluid weight gain were
calculated for each participant
throughout each data gathering time
period. The group ID fluid weight
Group standard
1.06
deviation
gain mean and standard deviation
were calculated at each time period
(see Table 4).
Box plots comparing the two
data collection times illustrate the
overall pattern of response to the MI
intervention (see Figure 1). The medi-
an remained the same; however, the
distribution differed. The extended
whiskers, both upper and lower, of
the second time period illustrate there
was a greater variance in fluid weight
1.17 0.53
change. Despite the increased vari-
ance, those above the median in quar-
tile Group 3 were fewer.
Paired t-tests and 95% confidence
intervals were used to examine the
difference in mean ID weight gain
between Time #1 (pre MI interven-
tion) and Time #2 (during MI inter-
vention) (see Table 5).
The difference between the two
data collection times is not statistically
significant. The confidence interval is

52 Nephrology Nursing Journal January-February 2017 Vol. 44, No. 1

 Figure 1
Box Plots of Average Interdialytic Weight Gain in Kilograms
sis, when a larger amount of fluid was

Before and During Intervention

removed, such as feeling “washed
out,” “as bad as the flu,” and extensive
“fatigue.” The last type includes com-
ments suggesting a vision to improve
4 their health to reap a reward, such as
“to stay healthy for my children and
grandchildren,” and “to be eligible for

3
a kidney transplant.”
Mastery includes comments of
frustration, such as “I hate the scale,
it’s staring me in the face,” as well as

2
how challenging it was to change.
One person stated: “It takes time to
master fluid intake, takes times to get
comfortable with and get the hang of

1
it. It’s not easy.” Some described chal-
lenges with self-control related to
thirst and fluid restrictions, comment-
ing it requires “mind over matter.”
0 Participant Satisfaction Survey
All participants completed a four-
question survey at the completion of
-1
the study. The majority of the partici-
pants (93%) felt that MI was helpful to
Before During
very helpful in understanding the
importance of fluid weight manage-
ment, and 77% felt it was helpful to

Table 5
very helpful in self-managing their

Differences in Average Interdialytic Weight Gain in Kilograms

fluid gains. The majority of partici-
pants (92%) were satisfied to very sat-
isfied with the MI approach to help
Pre During Difference
Group (Time 1) (Time 2) (1-2) 95% CI p-Value*
with self-management. Approximate-
ly half of the participants indicated an
Average ID
1.46 1.40 0.06 -0.21 to 0.33 0.66
interest in participating in MI tech-
weight gain
niques to help them self-manage
Standard
1.06 1.17 0.53
other hemodialysis challenges, in-
deviation
cluding phosphate levels, exercise,

N 17 17 17
and muscle strengthening.

* Paired t-test. Discussion

wide, suggesting a larger study is
required to determine a difference.
Participant Perceptions
Comments expressed by partici-
pants centered on the challenges they
experience when attempting to control
interdialytic fluid weight gain. Com-
ments aligned with three themes: open-
ing up, motivation source, and mastery.
Opening up includes statements of
normalization expressed when the par-
ticipant learned that others had similar
challenges. One participant expressed:
“It’s nice to know I’m not alone.”
Others described “suffering in silence.”
Motivation source is composed of
three types of comments. First is iden-
tification of uncomfortable physical
symptoms experienced before dialysis
with greater ID fluid weight gain, such
as episodes of edema and shortness of
breath. Next are discussions of uncom-
fortable physical symptoms post-dialy-
Overall, the difference of 0.06 kg
fluid weight gain between Time #1
and #2 is weak, suggesting that MI
alone as an intervention may be insuf-
ficient in altering ID fluid weight
gains. These findings are in line with
those of Russell et al. (2011), who
found that ID fluid weight gain was
less influenced by MI than other
health behaviors studied. However,
findings from this study are important
in that they underline the difficulty of
altering ID fluid weight gain in
patients on hemodialysis. The com-

Nephrology Nursing Journal January-February 2017 Vol. 44, No. 1 53

Enhancing Self-Care Management of Interdialytic Fluid Weight Gain in Patients on Hemodialysis:
A Pilot Study Using Motivational Interviewing
plex nature of the difficulty to change
behaviors associated with ID fluid
weight gain is reflected in patient per-
spective comments recorded through-
out the study. The high level of satis-
faction with MI reported in the sur-
vey is suggestive that MI may be an
important instrument in a tool kit of
interventions to aid patients on hemo-
dialysis in mastering the many neces-
sary behavior changes.
The purpose of a pilot study is to
explore the feasibility of a large-scale
study. Results found here indicate a
more robust approach to exploring
techniques or combinations of tech-
niques is required to support statistical-
ly significant results. Before moving to
a larger-scale study, researchers should
consider refining the study to address
limitations identified. For example,
inclusion criteria that clearly identify
patients who require behavior change
in ID fluid management may produce
more reliable data.
There are limitations inherent in
this study. First, it is a pilot study, and
results should not be generalized. As
a pilot study, the sample size is small,
limiting the opportunity to show sta-
tistical significance. Participation bias
likely occurred because patients
achieving their target weight were not
excluded, and patients who struggle
with large weight gains may be less
likely to participate. Measuring ID
fluid weight gain change was chosen
as evidence of behavior change.
Measuring this outcome alone did not
allow the patient the freedom to
choose which behavior to change, as
is recommended in the MI technique.
Time was a limitation. Patients dia-
lyze three times per week, which
equates to approximately 12 days in
the study timeframe. The short time-
frame of data collection may have
reduced the ability to achieve a signif-
icant behavior change.
Nephrology nurses are well posi-
tioned to support those whose health
trajectory has been altered to include
dialysis. These nurses who see
patients on a regular basis have the
opportunity to listen to and empower
patients toward behavior changes to
maintain an intact life. Patient-cen-
54
tered care is valued as essential to
promote effective health choices and
quality health care (Institute of
Medicine [IOM], 2001). Patient-cen-
tered care is holistic, collaborative,
and responsive (Sidani et al., 2014).
MI is known to be a collaborative,
patient-centered technique that is
effective in guiding, eliciting, and sup-
porting health behavior change.
Within dialysis units, the use of MI
principles is one tool nephrology
nurses can use to establish a collabo-
rative, patient-centered approach that
facilitates behavior change. Use of MI
principles by nurses and other health-
care professionals has reduced stress-
ful experiences for both patients and
nurses (McCarley, 2009; Wiley, Irwin
& Morrow, 2012). Additionally,
understanding readiness to change
and the techniques to aid in progres-
sion toward change action are known
to reduce frustrations of patients and
healthcare professionals (Ghaddar,
Shamseddeen, & Elzein, 2009). The
MI principles, stages of change, and
readiness ruler presented in this arti-
cle provide nephrology nurses work-
ing with patients on hemodialysis
quality tools and usable actions to
begin to influence behavior change.
Conclusion
This pilot study searched for an
effect of MI techniques on ID fluid
weight gain of patients established on
hemodialysis. Although no statistical-
ly significant change in ID fluid
weight gain occurred during the study
(not unusual in pilot studies), the
reduced number above the median in
quartile Group 3 suggests a trend
toward improved ID fluid weight
gain management. Patient comments
logged throughout the study pro-
gressed from “opening up” through
identifying their “motivation source,”
to “mastery” toward a goal. These
simple themes provide an illustration
of patients’ perspectives of progres-
sion toward motivation to change.
The patient response to the MI tech-
nique was positive. Participants
expressed that the MI coaching
helped them to better understand the
Nephrology Nursing Journal
importance of managing their ID
fluid weight gain. This acceptance of
information suggests progression
from pre-contemplation toward a
potential behavior change. Patients
commented they liked the MI
approach and expressed an interest in
participating in the approach to mas-
ter other dialysis-related health
behaviors. This extended interest sug-
gests some participants may have
begun to resolve their ambivalence
thus leading to motivation for change.
A bundled set of interventions that
include MI may be what is needed to
effectively provide a patient- cen-
tered, holistic approach to influencing
self-care fluid management. Future
research is needed to explore for full
effects of MI and to consider addi-
tional complementary tools to aid in
eliciting behavior change and moni-
toring symptom response.
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Wallston, K., Ikizler, A., &
Cavanaugh, K. (2010). Patient perspec-
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55
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Learning Outcome Learning Engagement Activity

After completing this learning activity, the learner will be able to provide Movilli, E., Camerini, C., Gaggia, P., Zubani, R., Feller, P., Poiatti, P., … Cancarini,
the results of a pilot study exploring the impact of coaching with moti- G. (2013). Magnitude of end-dialysis overweight is associated with all-
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SIGNATURE Strongly Strongly Paula Dutka MSN, RN, CNN, disclosed that she is a coordina-
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56 Nephrology Nursing Journal January-February 2017 Vol. 44, No. 1

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