The moderate-intensity participants reported that the training had less impact. Half the respondents reported that they did not remember much of the MI training and either forgot or did not use the newly learned MI skills.
Using MI skills. Both high- and moderate-intensity participants reported using open-ended questions, reflections, affirmations, motivation scales, and active listening.
Practitioners reported that MI helped them focus on patient-centered care, since MI is collaborative. Even when a session was not successful in leading to behavior change, practitioners felt more satisfied with the quality of the interaction.
Integrating MI into practice. The high- and moderate-intensity practitioners had different perceptions of using MI in daily practice. High-intensity participants thought MI required an initial time investment, but that would be balanced by a decrease in the number of follow-up visits needed and/or delay the time between visits. The moderate-intensity participants were more likely to report struggling with the amount of time MI took.
Suggestions for improving MI training. Practitioners from both training groups offered suggestions for improving MI training. Supervisor buy-in was deemed critical to getting other PACT members involved. Practitioners suggested providing compensation or making training mandatory to help motivate others to participate in MI training. Also, practitioners were ready to expand the MI training beyond smoking cessation to incorporate other diseases and multiple comorbidities.
The moderate-intensity participants suggested more training, practice, follow-up, and feedback. These participants also suggested boosterlike sessions.
Discussion
Champions and study practitioners reported that learning MI skills was useful. The participants felt that MI was consistent with their personal philosophies regarding patient-centered care and that MI had a positive impact on patient care. Practitioners and MI champions offered several insights for improving the delivery of MI training. First, practitioners and champions highlighted how important practice and feedback were to learning MI. Booster sessions, standardized patients, and critical feedback enhanced learning.
Second, champions reported that they wanted more training in how to teach MI. Third, practitioners and champions repeatedly stated that finding the time needed to become proficient in MI was difficult and that using the MI approach with patients took additional time during clinical sessions. However, participants in the high-intensity group reported more satisfaction with the quality of their patient encounters and the freedom to follow up with patients less often.
There were aspects of the environment and MI training program that facilitated the MI learning process. The high-intensity group cited booster session feedback as being reinforcing; the moderate-intensity group expressed a desire to practice their newly acquired skill and felt feedback and coaching would have enhanced their learning. Practitioners and champions reported that using a standardized patient to enhance experiential learning activities was an asset. Standardized patients have been used successfully in other training programs.21
Implementing an MI training program posed a number of challenges. The biggest barrier was lack of time. PACT members found it difficult to attend a half-day MI workshop, practice MI skills, and incorporate MI routinely into daily practice. However, without the investment of time, even basic MI proficiency is unachievable.22
This study highlighted several ways to improve feedback and coaching. First, the authors would expand the MI champion curriculum to include training to provide effective feedback/coaching. Second, the authors would train the standardized patient on how to provide feedback to the MI learner. As implemented, the standardized patient evaluated the learner only on whether the patient felt “heard” by the learner.
Perhaps most critical to the success of an MI training program is institutional support. There needs to be adequate time and space for the training process as well as support for ongoing learning and feedback as MI skills are refined. Furthermore, sufficient time is needed during patients’ appointments to allow for MI-oriented conversations. Time is an important, valuable, and scarce resource that institutions control. Administrators should realize that the up-front investment is likely to provide a downstream return as providers become proficient in MI.
There is an urgent need to find ways to incorporate training into the daily practice of busy HCPs. Although this study was limited by its small sample, it demonstrated the feasibility of implementing an MI training program for practitioners working in a busy primary care environment. This study offers concrete suggestions for overcoming barriers and enhancing facilitators, which can guide much needed larger studies as they examine MI training effectiveness on patient and clinician outcomes.
Champions and practitioners reported that learning MI was important, but opportunities to practice and receive critical feedback are needed to achieve proficiency and improve confidence. Both champions and study practitioners thought practicing with a standardized patient would enrich their learning. However, dedicated time for learning and practicing MI skills is critical and hard to arrange.