Why Motivational Interviewing (MI)?
In a previous blog article, we made the case for incorporating best practice to build an effective communication skill set into your organization to engage and activate patients; the evidence we presented supported the motivational interviewing (MI) approach. In brief:

1. MI is congruent with the literature on effective communication and engagement.

2. MI is the only health coaching approach to be fully described and consistently demonstrated as causally and independently associated with positive behavioral outcomes.^1-4

3. MI has been studied and improved for over 35 years, with successful application in the healthcare setting.

4. MI is standardized; therefore, we know how to teach it, measure it, and develop proficiency in a team of practitioners.

A Complex Skill Set
A limiting factor of the MI approach is that it is a complex skill set and does not lend itself to a typical “one-and-done” type of training. Like learning a foreign language, it takes practice, feedback and continuous support after the initial training over time to develop proficiency. Therefore, if your goal is to build measurable proficiency among your staff, it will be important to go beyond an initial MI training and implement both follow-up activities and a sustainability plan. See this clinical trial and this non-profit’s recommendations for more detailed information.

In addition, unless you build in the development and implementation of a sustainability plan into your training initiative, chances are high that momentum towards the new approach will stall and practitioners will lose their burgeoning skills, along with their enthusiasm. Therefore, your project should include a plan for both an initial MI training and a sustainability plan, which includes: structured follow-up activities, an internal mentor team, and anchoring the approach into the organizational culture. Before we discuss these components of a sustainability plan in length, let’s consider the initial MI training first – the foundation for implementing the MI approach into an organization.

Recommendations for Initial MI Training
An initial training should be designed as an immersion experience for participants. The goals of this training component are: to raise awareness about the importance of a client-centered approach; provide experiential learning about the differences between the traditional and MI approach; introduce foundational principles; practice strategies in a safe environment; and receive feedback in a small group format.

Most traditionally, this training is delivered in a two-day workshop, although some MI experts recommend that the 16 hours be delivered in four 4-hour blocks to allow time for practice and application in between training sessions.⁵ Additionally, there is evidence that demonstrate that an eLearning program designed as an initial MI training can match or better skill development. See Figure 1 below.

Regardless of the training format, be sure to:

• Contract with an expert in MI-based Health Coaching. Identify an MI expert or organization experienced in MI training. Although not mandatory, it is helpful if the lead trainer is a member of the Motivational Interviewing Network of Trainers (MINT) to ensure that she has the training background and proficiency to guide your team or organization. Secondly, the expert should be experienced in the use of MI in a healthcare setting that is similar to your own. Third, the expert should have experience working with other organizations and be able to provide evidence of successful training outcomes, along with the ability to objectively assess and evaluate the impact of the initiative with your organization. The expert should emphasize that training is simply the first step in an MI workforce development program; i.e., there should be a well-articulated plan for follow-up activities that will sustain improvement and build proficiency—whether face-to-face or online—per the evidence on MI proficiency development.

• Ensure that the training format is tailored. Workshop examples, activities, and discussions should reflect your setting and population. It can also be helpful if the facilitator is familiar with your assessment tools, new hire training, performance evaluations, and quality assurance standards.

• ​Emphasize the importance of full engagement by participants. To have a successful immersion experience, participants should be expected to attend the entire workshop and avoid distractions such as meetings, phone calls, texts, etc. Management can set the stage by prioritizing the training and providing a full explanation about the commitment to and value of adopting the MI approach.

• Encourage the participation of managers. To show commitment and managerial support for the initiative, managers at all levels should attend the workshop whenever feasible. Most importantly, if they attend, they should fully participate in the activities and discussion as a regular participant, versus sitting separately in the back and working on laptops.

During and after the initial training, the components of the sustainability plan should already be in place and in process.

Recommendations for Building a Sustainability Plan
There are three critical elements needed to build a successful sustainability plan after initial MI training:

1. Structured Follow-up Activities
2. Development of an Internal Mentor Team
3. Anchoring of the Approach into the Organizational Culture

Structured Follow-up Activities
The goal of follow-up activities is to provide structured activities so participants can practice and build their MI skill set. There are multiple follow-up activities that are effective and can be seamlessly integrated into current quality assurance efforts. Some of these include:

Feedback and individualized skill-building sessions using actual patient encounters. This type of activity is considered the gold standard for building proficiency that is linked to clinical outcomes. Assessment or “coding” should be provided by trained coders using a validated, standardized tool such as the Motivational Interviewing Competency Assessment (MICA), which has demonstrated its utility in developing the MI skill set of clinicians across a large organization. See Figure 2 for a brief sample of a feedback report.

Recording of patient encounters. This activity is both necessary for receiving productive feedback from health coaching experts and to allow clinicians to review their own sessions. Although this step can feel daunting at first for your Legal and IT team, there is solid precedence for this type of quality assurance and your MI expert should be able to share practical options and guide you through the process.

Case review sessions where the MI approach is discussed. By ensuring that MI strategies are discussed along with clinical practices, this type
of case review activities support the continued discussion and integration of the MI approach into daily practice.

Refresher courses. Many organizations find it helpful to provide refresher or advanced MI courses or workshops on a regular basis. Once your organization has developed an internal mentor or trainer program (see below), you will be less dependent on an outside consultant.

Development of an Internal Mentor Team
The goal of an internal mentor team is to develop organizational resources to provide ongoing training and mentoring for new and existing team members.

Step 1:  Contract with an expert in MI Health Coaching (see above). Your MI expert should be willing and able to assist you in identifying internal MI mentors and/or trainers, and provide a detailed plan upon request for a comprehensive training and development program. This plan should be coordinated with the initial training and follow-up activities to allow opportunities for the new mentors to shadow experienced staff and receive feedback on their own mentoring/training efforts.

Step 2:  Identify internal MI mentor candidates. Aptitude for the MI approach can be assessed by using scores from the validated, standardized tool that should be used in the feedback and skill-building process (see above). Effective mentors also show an interest in or passion for making a difference in the lives of patients and are excited about growing their skill set in a proven approach such as MI. Your MI expert can provide you with a list of possible candidates based on their observations in the initial training and on their performance from the validated assessment tool.

Step 3:   Make mentor selections. Leadership will then review the list and make their selections based on their own managerial and organizational considerations. Part of this process is contacting the individuals to assure that there is adequate interest in the position. [NOTE: While it can be tempting to choose training, quality or supervisory staff for the mentor role, it is key that the individual has fully engaged in the MI training process, plus also demonstrates aptitude. Additionally, the candidates should either carry an active caseload of patients or have another way of practicing their health coaching skill set. If the mentor cannot practice their skills, it is almost impossible to build the required proficiency in MI to be an effective mentor. Moreover, a credible mentor will need to provide and discuss realistic case studies with other clinicians.]

Step 4:   Build MI and Mentor Skills. Following selection, the mentor will need to participate in structured training activities to build their MI and mentor skills. Typically, they would be working with the MI expert or organization during this time in an individual or team setting. They will also be assessed periodically with the assessment tool and provided expert feedback. In addition, a self-paced online program, with assignments and resultant feedback, can be an efficient and effective way to train staff at multiple locations with diverse schedules.

Step 5:   Mentor Shadowing, Practice, and Feedback. Once the mentors reach the required MI proficiency level and have finished their mentoring skill-building program, they start shadowing expert staff in their mentoring sessions, with a debrief afterwards. Once they are ready, the new mentors provide their first mentoring sessions for a teammate with shadowing support and debrief from expert staff.

Step 6:   Select Appropriate Mentor(s) for Internal MI Trainer(s). If your organization is interested in developing an internal MI trainer, your MI expert should be able to train one or more of your mentors, then sponsor them for the Motivational Interviewing Network of Trainers (MINT) Train the Trainer Program (TNT). As application to this program is highly competitive, your leadership will need to select the best candidate(s) from the mentor pool based on MI proficiency levels, leadership and passion, along with group presentation and small group facilitation skills.

While the MI follow-up activities and internal mentor program are important to the success of your sustainability plan, so is the last key element.

Anchoring of the Approach into the Organizational Structure
To ensure that our initiative is successful, we must consider how we will ensure that the MI approach is incorporating fully into the culture and norms of our organization. Kurt Lewin's Change Management Model (see Figure 3) is a tried and true approach towards organizational change. There are three stages of change: unfreeze, change, refreeze. In our application of adopting a more evidence-based patient-centered approach, we can easily relate these to the elements in our sustainability plan.

We unfreeze when we: prepare our managers for the initiative; hire the right consultant, carefully plan the rollout and follow-up; create the imperative for the rationale of such an initiative; and craft a message that makes it clear this change is a priority and how it fits in with the organization’s mission.

Our change here is obvious; it includes the initial training, the follow-up activities, and the development of internal resources to continue the initiative.

The refreeze stage is the one that is often neglected; yet in our initiative of incorporating the MI approach it is critical. This stage is needed to help people and the organization internalize or institutionalize the changes. This means making sure that the MI approach is applied all the time in all activities; it is only when it is incorporated into everyday practice that you create new norms and will see resultant outcomes. It is likely that management will need consider reinforcement for learning/using the new approach, along with changes in policies, procedures and other infrastructure to ensure that the change is permanent. Your MI expert should be able to assist you in this process; however, some examples include tweaking your: hiring process, quality assurance checklist, assessment tools, patient materials, protocols for patient outreach, and performance evaluations. Another example is the provision of release time and recognition for internal mentors and trainers.

Conclusion
While the process of planning and implementing an MI training and sustainability initiative may seem daunting, keep the benefits of a successful change to an evidence-based health coaching approach in the forefront. Remember, all the clinical training, checklists, algorithms, and IT interfaces may be helpful to operations management, but they won’t improve patient engagement, patient activation, and clinical outcomes – health coaching is the intervention for chronic care management where the patient must follow through with the treatment plan. Most organizations find that such an investment in a proven, best practice approach for improving engagement and health behavior is well worth the investment of time and resources.

References:

¹ Butterworth SW, Linden A, McClay W. Health Coaching as an Intervention in Health Management Programs. Dis Manage Health Out 2007;15(5):299-307.

^​2 Noordman J, van der Weijden T, van Dulmen S. Communication–related behavior change techniques used in face-to-face lifestyle interventions in primary care: a systematic review of the literature. Patient Educ Couns 2012;89(2):227-44.

^​3 Wolever RQ, Simmons LA, Sforzo GA, et al. A Systematic Review of the Literature on Health and Wellness Coaching: Defining a Key Behavioral intervention in Healthcare. Globl Adv Health Med 2013;2(4):38-57.

⁴ Olsen JM, Nesbitt BJ. Health Coaching to Improve Healthy Lifestyle Behaviors: An Integrative Review. Am J Health Promot 2010;25(1):e1-e12.

⁵ Miller W, Mount K. A small study of training in motivational interviewing: Does one workshop change clinician and client behavior? Behav Cogn Psychother 2001;29(4):457-471.