Primary care providers (PCPs) need effective tools for activating health behavior change for the 125 million Americans living with a chronic condition.1 Smoking is an important and difficult behavior to change, and a motivator for quitting is tobacco cessation advice from a PCP.2,3 However, few PCPs provide comprehensive tobacco cessation counseling as part of routine care.4,5 One perceived barrier that providers report is their lack of training to be effective tobacco cessation advocates.4,6-8
Motivational interviewing (MI) promotes behavior change by using a nonadversarial approach aimed at resolving patient ambivalence. Motivational interviewing tools, such as asking open-ended questions, providing summary statements of what the patient expresses, reflective listening, and affirmations, are used to spur an intrinsic drive to change. These techniques have been applied to a broad range of health behaviors with positive outcomes and demonstrated efficacy.9-11 Furthermore, MI can be used in primary care for changing tobacco use, alcohol consumption, physical activity, and diet.12-14
Despite its efficacy, MI can be time-intensive to learn. Fortunately, even abbreviated MI can influence patient behavior.15,16 Rollnick and others have developed MI interventions that are deliverable in 5 to 10 minutes.17,18 These brief interventions focus on performing a rapid assessment of patients’ perceived importance and self-efficacy for change.17,18
There is increased interest in training health care professionals (HCPs) in MI, yet there is no consensus on the most effective training approach.19,20 Practitioners with many competing priorities often like to learn new skills through self-study or onetime workshops. Yet evidence suggests that these are not effective methods for gaining MI proficiency. Instead, MI training sessions that offer feedback and coaching are more effective in helping participants retain MI skills over time.21,22
The authors developed and successfully pilot-tested an MI training program called the Motivational Interviewing Smoking Treatment Enhancement Program (MI-STEP) for HCPs. This program was designed to facilitate tobacco cessation care in the VHA primary care patient centered medical home, which VHA calls patient aligned care teams (PACTs).23 The main conclusions of this pilot study have been reported elsewhere.24
The objective of this article is to describe the process evaluation the authors conducted during the MI-STEP study to gain a better understanding of how the implementation of the MI training program could be improved. The authors identified barriers and facilitators from the perspectives of MI champions and PACT practitioners.
Thirty-four PACT practitioners (physicians, nurse practitioners, registered nurses, licensed practical nurses, and pharmacists) at 2 VA medical centers were randomly assigned to a high- or moderate-intensity MI training program during the summer of 2012. This training was delivered by “MI champions,” who were recruited from PACTs and who attended a 3-day advanced training class on MI. The training included MI skills practice, group case analysis, various role-play exercises, and didactics adapted from the Rx for Change program.25 The curriculum also addressed tobacco cessation counseling using the national tobacco cessation guideline.2 Each site’s health behavior coordinator (HBC) also was recruited to be an MI champion. The HBCs are typically psychologists who have received prior training in MI as well as facilitator and clinician coaching. At the VA, HBCs are charged with integrating preventive services into care. The participating sites’ institutional review boards approved all study procedures.
MI-STEP Training Program
All 34 practitioners attended a half-day on-site MI training workshop led by the site’s HBC. This training covered the basics of MI and used interactive learning methods such as role-play (Table 1). The study practitioners also received self-study materials, and throughout the study period had access to the MI champions. Practitioners who were randomized to high-intensity MI training also attended 6 supplemental 1-hour “booster sessions” to enhance specific MI skills. The MI champions led 3 of the 1-hour booster sessions with a standard agenda, including patient cases and MI exercises. During the other 3 booster sessions, participants used patient cases to interact with a standardized patient over the telephone, and the MI champions provided feedback and coaching.
Six months after the program’s completion, investigators conducted an evaluation of the MI-STEP training program with MI champions and study practitioners. One-hour focus group sessions (2 in Minneapolis; 1 in Denver) were conducted with the MI champions by a co-investigator in Minneapolis and a facilitator in Denver. Notes were taken during the sessions. MI champions were asked about the quality of their training sessions, challenges to getting PACT members to participate in the site training, challenges to teaching MI, and how they felt MI fit within VA health care philosophy.