Article Archive
September/October 2020

Using Motivational Interviewing to Prevent Falls
By Lindsey Getz
Today’s Geriatric Medicine
Vol. 13 No. 5 P. 22

When gathering information from patients, the right questions can make all the difference.

For older adults and the providers who care for them, falls are a serious concern. Every year, 1 in 4 adults older than 65 falls. According to the Centers for Disease Control and Prevention, falls are the leading cause of injury-related deaths among older adults in that age group. These are key reasons why fall prevention is so important. However, fall prevention traditionally focuses on many recommendations directed at older adults but doesn’t take into account how those adults feel about the matter. But research and anecdotal experience have indicated that an approach that incorporates motivational interviewing (MI) can be considerably more effective.

Kathlynn S. Northrup-Snyder, PhD, RN, CNS, and Hiroko “Hiro” Kiyoshi-Teo, PhD, RN, both assistant professors at Oregon Health & Science University’s School of Nursing, have been researching the ways MI can assist in fall prevention, and the findings have been promising.

According to Kiyoshi-Teo, falls can be a sensitive topic for older adults, for whom most fall prevention discussions very quickly start to sound and feel like a loss of freedom.

“So often the conversations that we have around fall prevention start to make older adults feel like they are losing control,” Kiyoshi-Teo says. “It could be something as seemingly small as switching to practical footwear. Maybe a patient has fallen because of wearing heels, but wearing heels was one of the last ways they still felt stylish. With traditional fall prevention, you’re not really thinking about how those changes affect the person.”

By failing to address the impact of such suggestions, Kiyoshi-Teo says, there’s a good chance you will not get patient engagement. It’s something she witnessed first-hand over two decades as a hospital nurse who has regularly worked in fall prevention. Patient engagement, she observes, always seemed to be “hit or miss.” Some patients follow through on recommendations, but many don’t.

Talking to Northrup-Snyder about her research on MI, however, was an “aha moment” for Kiyoshi-Teo and demonstrated how it could have a tremendous impact on patient follow-through. “When I started asking patients about what fall prevention means to them—and really listening to their perspective—I saw the potential for significant patient engagement,” Kiyoshi-Teo says. That opened the door to progress and change. “I think for me, in a nursing mindset, I initially thought that fall prevention was relatively simple—it’s using a walker or a cane or it’s doing some exercises—but it’s not always that simple for patients,” Kiyoshi-Teo adds. “So it’s clear we have to change our approach.”

MI and Fall Prevention
According to the Motivational Interviewing Network of Trainers, the current version of MI is described in detail in Motivational Interviewing: Helping People Change, 3rd edition by Miller and Rollnick and defined as a “collaborative, goal-oriented style of communication with particular attention to the language of change. It is designed to strengthen personal motivation for and commitment to a specific goal by eliciting and exploring the person’s own reasons for change within an atmosphere of acceptance and compassion.”

Northrup-Snyder explains that MI takes a “conversational style approach” to inspiring behavioral modifications. That, she says, means using more reflections than questions and letting the client fill more of the “talk space” than the provider. Although providers, because there is a certain information they need to gather during their time with patients, are generally inclined to go through a standard checklist of questions, “it is possible to collect client information through good, open-ended questions and empathic reflections reducing needs for survey questions,” Northrup-Snyder says.

It often makes sense to start the MI process with an open-ended question such as, “What brings you here today?” From this question alone, Northrup-Snyder says, you can gather a wealth of important information that would check off a lot of boxes.

She then suggests some additional questions.

• When you think of fall risk or prevention, what comes to mind?
• What is your experience with falls …
- For this [current] fall?
- Within the last year?
- Happening to someone you know?
• What about this worries you most?
• On a scale from 1 to 10, with 1 being not ready at all and 10 being completely ready, how confident/ready are you to [insert recommendation, such as “use a cane?”]

This approach helps patients to feel heard and that their needs are being met. And that typically means less resistance to change, Northrup-Snyder says.

“Once patients genuinely feel heard, they naturally start to lower their resistance,” she adds. “But sometimes that is easier said than done for providers. Part of it means stepping away as the expert. You must remind yourself that the patient is the expert and you are there to provide the health care or medical context around the situation.”

Another aspect of successful MI, Northrup-Synder says, is the inclusion of affirmations of strengths, talents, and efforts related to change. Working with patients at the VA hospitals, one affirmation that came to Kiyoshi-Teo’s mind was “warrior.” Many of her patients were men who’d fought in war and now are fearful of being considered weak. Translating these new changes into skills they have as warriors for navigating new situations can help.

Improving Your Skills for Patient Success
One way to improve your MI skills is to record your patient conversations and listen to them afterwards. Pay attention to how your patient conversations flow and whether you ask many open-ended questions or you lead the conversation.

“Recording and listening to patient interactions is admittedly awkward and was uncomfortable for me when I started doing it,” Kiyoshi-Teo recalls. “However, it helped me to realize that I had the framework down—I do ask a lot of questions—but I had to make some subtle changes. Hearing what’s important to the patient and being careful to not come across as forcing change are what really helped me to start seeing patients lower their resistance.” She even clearly remember when one of her more resistant patients accepted that he ought to be practicing some of the fall prevention recommendations he’d been given. Having come to this realization on his own was powerful.

But there’s more than anecdotal evidence. Kiyoshi-Teo and Northrup-Snyder have been involved in research that confirms success of the MI approach. In a study published in the Journal of Gerontological Nursing, a two-arm, unblinded, pilot randomized controlled trial was conducted in a hospital setting to compare MI to standard fall prevention practice at bedside. The group utilizing MI reported less fear or falling and also maintained fall prevention behaviors over time. As a result, the study demonstrates the feasibility of the delivery of MI for fall prevention at a hospital setting.

Are You Already Practicing MI?
Understanding that MI involves asking a lot of questions, many providers might assume they’re already practicing it. However, there is a difference between merely asking questions and true MI.

“One of the traps that providers fall into is that we’re trained to ask questions, but they’re usually closed and narrow,” Northrup-Snyder says. “Close-ended questions can really kill the opportunity to have beautiful patient reflections. But that’s how our forms are built and that’s how we’re taught.”

A lack of comfort with affirmations is another way in which providers may fall short of practicing true MI.

“Americans are generally just not that comfortable with giving positive affirmations, but they are important because they raise confidence,” Northrup-Snyder says. “We must remind patients they are capable. So, with the warrior affirmation, I might say, ‘It’s clear that you are a warrior because of your service and your time spent in the field doing XYZ. How did you draw on that warrior strength at challenging times in your past?’”

When practicing MI, Northrup-Snyder also says that before giving patients any information or advice, the provider should assess what the client already knows. This has to do with putting the patient in that expert role, she explains.

“This means taking off your expert hat and holding back from offering lots of advice and information before you find out what the patient already knows,” she continues. “Then, fill in the blanks in a generic ‘other people have tried XYZ’ type of manner. Ask what this information means to the client. Recognizing their autonomy to take or leave any information will reduce resistance.”

Another important piece of the puzzle, she says, is recognizing signs or language indicating that that patients aren’t listening or are feeling defensive.

“When you hear ‘Yeah, but …,’ it’s that the patient is not feeling as though you’re hearing them—so they’ve started tuning you out,” she says.

This is not to say you shouldn’t be providing the patient with information—but you need to continually check in and see what it means to them.

“Say, ‘I gave you a lot of information, what do you make of it?’” Northrup-Snyder says. “What you do not want to assume is that they understood everything you said or that the recommendations will work for them.”

Some of the changes in questions are subtle but make a world of difference, Northrup-Snyder says. Just asking “What do you think of what I told you?” is really opening it up to conversation—and that is powerful in guiding the client, she adds. You’re not making it all about your recommendations, but rather about what the patient thinks—and that can make room for discovering patient objections and unique problem solving.

Devoting the Time
Although it’s a successful approach, a potential barrier to adoption of MI for fall prevention may be the perceived time it will take to have conversational visits with patients. Providers often have time constraints to consider.

Kiyoshi-Teo admits that when she first adopted MI, she did feel it was time-consuming, but, as her skills improved, that changed. “It did feel like it took me more time early on because I was not skilled at guiding the conversation—and I think that’s a lot of clinicians’ fear,” Kiyoshi-Teo says. “I think providers worry that if they ask open-ended questions, who knows where the conversation will go. But there are ways to guide the conversation. It’s not merely listening.”

Northrup-Snyder agrees. “MI is directional,” she says. “It’s listening/hearing/understanding—and it’s okay to interrupt gently and with compassion in a way that you can let them know, ‘I heard you.’ You can move the conversation along. There are providers who have become quite skilled at doing this in a gentle way. And as providers become more adept at using MI, they have said it can actually save them time in the long-run.”

Looking Ahead
As more providers consider adopting MI for use in their fall prevention approach, Northrup-Snyder and Kiyoshi-Teo say honing your skills and learning more about the process can make a big difference. Utilizing Motivational Interviewing Network of Trainers resources and including their recommendation for further reading can be very helpful. There are also MI coaches who can confidentially review your patient conversation recordings and offer insight. There might also be a specialist on your team who can help. Social workers, physical therapists, and psychologists are some examples of experts who often have rich MI training.

For providers who are serious about implementing these techniques, it can pay off with better compliance and ultimately less fall risk.

“I think as providers, we sometimes struggle with not always being the boss—and MI definitely puts the patient in that role,” Northrup-Snyder says. “But that’s where we start to see true progress. When patients believe we aren’t trying to take freedoms or control away but that we are letting them guide the process, that’s when we start to see real change.”

— Lindsey Getz is an award-winning freelance writer in Royersford, Pennsylvania.