Training primary care clinicians in motivational interviewing: A comparison of two models

Highlights

• Few health professionals utilize motivational interviewing (MI) as part of routine practice due to lack of expertise and training.

• This study evaluated two training models for motivational interviewing and tobacco cessation counseling for primary care clinicians.

• Using enhancement strategies (i.e., MI clinical champions as peer coaches and telephone interactions with simulated patients) to supplement or boost initial training workshops is feasible in busy primary care settings.

• Booster training sessions improve proficiency of MI training programs for primary care clinicians.

Abstract

Objectives

To evaluate implementing two training models for motivational interviewing (MI) to address tobacco use with primary care clinicians.

Methods

Clinicians were randomized to moderate or high intensity. Both training modalities included a single ½ day workshop facilitated by MI expert trainers. The high intensity (HI) training provided six booster sessions including telephone interactions with simulated patients and peer coaching by MI champions over 3 months. To assess performance of clinicians to deliver MI, an objective structured clinical evaluation (OSCE) was conducted before and 12 weeks after the workshop training.

Results

Thirty-four clinicians were enrolled; 18 were randomly assigned to HI. Compared to the moderate intensity group, the HI group scored significantly higher during the OSCE for three of six global Motivational Interviewing Treatment Integrity scale scores. There was also significant improvement for three of the four measures of MI counseling knowledge, skills and confidence.

Conclusions

Using champions and telephone interactions with simulated patients as enhancement strategies for MI training programs is feasible in the primary care setting and results in greater gains in MI proficiency.

Practice implications

Results confirm and expand evidence for use of booster sessions to improve the proficiency of MI training programs for primary care clinicians.

Introduction

Tobacco use is the leading preventable cause of morbidity and mortality in the United States [1]. Tobacco use is a chronic disease and clinical practice guidelines for addressing tobacco use emphasize a chronic disease model of care [2]. It is well established that counseling from a clinician approximately doubles patients’ odds of tobacco cessation; however, few health professionals provide comprehensive tobacco cessation counseling as part of routine practice [2]. Key barriers to doing so are lack of expertise and training, lack of time, and not believing that cessation counseling is a high priority during clinical encounters. As a result, most tobacco users do not receive comprehensive, state-of-the science tobacco cessation treatment (e.g., behavioral counseling and pharmacotherapy) [3]. Additionally, although most smokers want to quit smoking, many smokers report low levels of motivation to quit. Therefore, current guidelines recommend motivational interventions provided by healthcare providers to encourage patient cessation and participation in evidence-based treatments [2]. Motivational interviewing (MI) is an evidence-based counseling practice directed at enhancing personal motivation for behavioral change. Motivational interviewing is patient-centered and helps patients identify and resolve discrepancies between their actual and desired behavior, and enhances motivation to make lifestyle changes [4]. It has demonstrated effectiveness for increasing quit attempts and successful smoking cessation [5], [6].

The Department of Veterans Affairs (VA) and other US healthcare systems are implementing the patient-centered medical home as a model for primary care redesign. The patient-centered medical home is an expanding healthcare delivery model, rooted in a team-based approach that delivers efficient, comprehensive and continuous care through active communication and coordination of healthcare services [7], [8]. Within the VA, this initiative is called the Patient Aligned Care Teams (PACT) and creates, expanded opportunities for counseling patients on smoking cessation to include nurse care managers, pharmacists, and behavioral health practitioners. In addition, the VA has determined that there is a need to train these primary care PACT team members in motivational interviewing in order to facilitate health behavioral change such as smoking cessation. Despite the promise of MI and this initiative from VA, only one previous study has examined training VA primary care clinicians in MI [9]. While they reported improvement in MI knowledge and confidence, this study did not use a randomized design, or objective, gold-standard outcome measures.

In other healthcare settings, most studies evaluating MI training programs have lacked adequate control groups to clearly understand the relative effect of training modalities on improving MI knowledge and skills. Furthermore, most studies relied on self-reported outcomes from program participants rather than objective assessments of MI skills. In one well-designed, randomized trial of MI training for substance abuse healthcare professionals, MI skill proficiency was improved for those trainees who received follow-up coaching and feedback relative to a control group and a training group that received a 2-day workshop only [10]. This study and a systematic review have suggested that MI training programs should utilize a “relapse prevention” strategy following initial training but that optimal training formats are unknown and further study with various populations of healthcare professionals is needed [11].

Therefore, we developed and tested a MI and tobacco cessation treatment training program for primary care clinicians. The objective of this pragmatic, randomized controlled trial was to evaluate the performance of high intensity (½ day workshop training plus follow-up training with simulated patients and peer coaching) versus moderate intensity (½ day workshop training without follow-up) training for primary care clinicians in delivering MI and tobacco cessation care. We hypothesized that primary care clinicians receiving high intensity training would acquire more objectively measured skills for MI and tobacco cessation counseling compared to those receiving moderate intensity training.