Deconstructing proficiency in motivational interviewing: mechanics of skilful practitioner delivery during brief simulated encounters

Mechanisms of Motivational Interviewing: a Conceptual Framework to Guide Practice and Research

Reviews of the motivational interviewing (MI) training literature demonstrate MI is a nuanced skill set that takes carefully planned didactic training, application of skills in context-specific practice settings, and ongoing support to promote reflective practice and sustained proficiency. Despite the robust knowledge base related to training and how MI works to achieve favorable outcomes, these two literature bases are not well integrated. In an effort to inform and guide future research, we propose the mechanisms of motivational interviewing (MMI) conceptual framework, which expands upon previous work. Specifically, the framework adds training as an ongoing process consistent with Bennett-Levy's (Behav Cogn Psychother 34:57-78, 2006) model of skill development and acquisition to the existing two-path framework that helps us to understand how MI works to achieve its desired effects (Magill et al., J Consult Clin Psychol 82:973-983, 2014). Herein, we describe measures used to evaluate the mechanisms within the four MMI framework links: initial training to competency, competency to proficiency, proficiency to talk about change, and talk about change to behavior change. Next, we synthesize the literature associated with each of the mechanisms of the MMI. We conclude by discussing implications for practice and research. This framework offers a more complete path structure to understand the mechanisms of change associated with MI that could improve our understanding of inconsistent effect sizes observed across prior trials evaluating MI effectiveness.

Embedding and sustaining motivational interviewing in clinical environments: a concurrent iterative mixed methods study

BACKGROUND

Motivational interviewing (MI) is internationally recognised as an effective intervention to facilitate health-related behaviour change; although, how it is best implemented and maintained in everyday clinical practice is not so clear. The aim of this study is to understand how MI as an intervention can be embedded and sustained in the clinical practice and learning environments.

METHODS

A concurrent iterative mixed methodology was utilised. Data collection occurred in two parts: a scoping review to identify reported barriers and enablers to embedding and sustaining MI in healthcare settings, and a survey of health professionals at an international clinical educator workshop on the topic. Results from both methods were integrated at the analysis phase ('following a thread') to understand how MI is embedded and the fidelity sustained in the clinical environments. Complexity theory as a conceptualising framework was utilised.

RESULTS

Eleven studies were included, and 30 health professionals were surveyed. Sustainability of MI at micro-clinical levels can be fostered through use of enabling technology, focus on patient-centred care, personnel development and process improvement. At the meso-organisational level, developing shared vision, creating opportunities and an organisational culture supportive of continuous learning are relevant issues. At the macro levels, adopting systems thinking and a learning organisation approach is important for sustaining MI.

CONCLUSIONS

In addressing the recognised barriers to embedding and sustaining MI in health service provisions, clinical educators could potentially play a central role as change agents within and across the complex clinical system.

Teaching health science students foundation motivational interviewing skills: use of motivational interviewing treatment integrity and self-reflection to approach transformative learning

BACKGROUND

Many undergraduate and graduate-entry health science curricula have incorporated training in motivational interviewing (MI). However, to effectively teach skills that will remain with students after they graduate is challenging. The aims of this study were to find out self-assessed MI skills of health students and whether reflecting on the results can promote transformative learning.

METHODS

Thirty-six Australian occupational therapy and physiotherapy students were taught the principles of MI, asked to conduct a motivational interview, transcribe it, self-rate it using the Motivational Interviewing Treatment Integrity (MITI) tool and reflect on the experience. Student MI skills were measured using the reported MITI subscores. Student assignments and a focus group discussion were analysed to explore the student experience using the MITI tool and self-reflection to improve their understanding of MI principles.

RESULTS

Students found MI challenging, although identified the MITI tool as useful for promoting self-reflection and to isolate MI skills. Students self-assessed their MI skills as competent and higher than scores expected from beginners.

CONCLUSIONS

The results inform educational programs on how MI skills can be developed for health professional students and can result in transformative learning. Students may over-state their MI skills and strategies to reduce this, including peer review, are discussed. Structured self-reflection, using tools such as the MITI can promote awareness of MI skills and compliment didactic teaching methods.

Validation of the one pass measure for motivational interviewing competence

OBJECTIVE

This paper examines the psychometric properties of the OnePass coding system: a new, user-friendly tool for evaluating practitioner competence in motivational interviewing (MI). We provide data on reliability and validity with the current gold-standard: Motivational Interviewing Treatment Integrity tool (MITI).

METHODS

We compared scores from 27 videotaped MI sessions performed by student counselors trained in MI and simulated patients using both OnePass and MITI, with three different raters for each tool. Reliability was estimated using intra-class coefficients (ICCs), and validity was assessed using Pearson's r.

RESULTS

OnePass had high levels of inter-rater reliability with 19/23 items found from substantial to almost perfect agreement. Taking the pair of scores with the highest inter-rater reliability on the MITI, the concurrent validity between the two measures ranged from moderate to high. Validity was highest for evocation, autonomy, direction and empathy.

CONCLUSION

OnePass appears to have good inter-rater reliability while capturing similar dimensions of MI as the MITI. Despite the moderate concurrent validity with the MITI, the OnePass shows promise in evaluating both traditional and novel interpretations of MI.

PRACTICE IMPLICATIONS

OnePass may be a useful tool for developing and improving practitioner competence in MI where access to MITI coders is limited.

Complementary Tools to Empower and Sustain Behavior Change: Motivational Interviewing and Mindfulness

Improving health behaviors is fundamental to preventing and controlling chronic disease. Healthcare providers who have a patient-centered communication style and appropriate behavioral change tools can empower patients to engage in and sustain healthy behaviors. This review highlights motivational interviewing and mindfulness along with other evidence-based strategies for enhancing patient-centered communication and the behavior change process. Motivational interviewing and mindfulness are especially useful for empowering patients to set self-determined, or autonomous, goals for behavior change. This is important because autonomously motivated behavioral change is more sustainable. Additional strategies such as self-monitoring are discussed as useful for supporting the implementation and maintenance of goals. Thus, there is a need for healthcare providers to develop such tools to empower sustained behavior change. The additional support of a new role, a health coach who specializes in facilitating the process of health-related behavior change, may be required to substantially impact public health.

Standardized patients: a promising tool for health education and health promotion

Standardized patients (SPs) are trained actors who are used to engage health care providers in various types of clinical encounters for the purposes of training and evaluation. In the past, SPs have most often been a tool for training clinicians in "traditional" medical skills such as the taking of medical histories or the conduct of physical exams. More recently, however, SPs have been increasingly used to assist in the development and assessment of psychosocial skills, including those related to patient-centered communication, relationship building, and motivational interviewing. Given this shift, it is argued that the time is ripe for exploring ways that health educators can adopt SP methodologies, whether for providing continuing education for individual providers or evaluating organizations or programs. This article introduces ways of using SPs and discusses strengths and challenges related to various approaches.