September 30, 2015 by Nicholas Spence
The increasing use of motivational interviewing in clinical practice for lifestyle behavior change is far from surprising as the evidence base demonstrating its merits is growing daily. If, however, motivational interviewing is going to achieve its full potential in primary care settings, there needs to be more work done to understand the best way to train clinicians. Without a doubt, appropriate counseling is premised on adequate skills, knowledge, and abilities of the health care provider.
The study by Fu et al. (2015) in Patient Education and Counseling sought to assess the relative merit of two training models (moderate vs. high intensity) of motivational interviewing in a primary care setting focused on tobacco use. For busy clinicians, in a world where time is always short and efficiency is of significant importance, training models for motivational interviewing must be particularly sensitive to these issues in this population while maintaining standards of practice. This is one key dimension of the study.
Fu and colleagues used a randomized research design with 34 participants, including physician assistants, nurse practitioners, nurses, and pharmacists, working in the Department of Veteran Affairs (USA) on Patient Aligned Care Teams focused on smoking cessation. Participants from various sites were randomized into two motivational interviewing training programs, moderate intensity (n=16) and high intensity (n=18). Both groups had motivational interviewing champions or site leads (clinician who receives additional motivational training); motivational interviewing expert trainers (clinical psychologists with expertise in motivational interviewing); one half day training workshop (foundational knowledge of motivational interviewing, video examples, practice scenarios); and self-study materials (presentation slides, worksheets, educational pocket cards). In addition, the high intensity training program included six one hour booster sessions administered over three months, focused on sustaining existing knowledge and improving skills, including telephone interactions with simulated patients and peer coaching.
Using a standard measure to assess motivational interviewing proficiency called the Motivational Interviewing Treatment Integrity or MITI 3.1.1, data were gathered at two time points: baseline or pre-training and at 12 weeks post-training.
What were the findings? There were significant improvements in the high vs. moderate intensity training program over the course of the study for all clinicians. Specifically, positive changes in the MITI proficiency scores related to evocation, collaboration, use of open questions, and number of motivational interviewing adherent behaviors were observed. Also, there were improvements in self-reported knowledge, counseling skills, and confidence, which were positively related to actual proficiency.
Based on this work, one half day training workshop followed by six short one hour booster sessions, including telephone interactions with simulated patients coupled with peer coaching, can enhance the motivational interviewing proficiency of clinicians. As a relatively successful training program with a reasonable time commitment, there is promise in terms of the scalability of this work to a variety of clinical settings.
Despite the merits of the study, there are some issues left to resolve: How can we maximize attendance at training sessions given the variance in rates across providers? For example, booster session attendance indicated marked differences among clinicians, including nurse practitioner, physician, and physician assistant (57%), nurses (83%), and pharmacists (87%). Can fewer booster sessions yield similar levels in motivational interviewing skills? Do these findings translate to real clinical encounters? Finally, are these findings applicable to other primary care settings and teams addressing other health outcomes, such as obesity? Yes, this is an important area of inquiry. The development of evidence based motivational interviewing training protocols will lead to vast improvements in clinician skills, knowledge, and abilities, resulting in optimal outcomes for patients.