Motivational Interviewing Implementation in Primary Care: A “Terrifying Challenge” Becoming a “Professional Revelation”

Abstract

Introduction

Motivational interviewing (MI) is an evidence-based counseling approach within primary care. However, MI rarely translates to practice following introductory training programs, and a lack of evidence regarding its implementation persists today. This study describes primary care clinicians’ professional transformation in implementing MI through interprofessional communities of practice (ICP-MI).

Method

Qualitative data collection involved the research journal, participant observation of four ICP-MIs (76 hours/16 clinicians), and focus groups. A general inductive approach was used for data analysis. Results were conceptualized based on the Consolidated Framework for Implementation Research.

Results

Four processes of MI implementation in primary care are presented as a motivational endeavor: ambivalence, introspection, experimentation, and mobilization. The clinicians were initially ambivalent, taking into consideration the significant challenges involved. After introspecting actual practices, they realized the limits of their previous clinician-centered approaches. The experimentation of MI in the workplace followed and enabled clinicians to witness MI feasibility and its added value. Finally, they were mobilized to ensure MI sustainability in their practices/organization. Intrinsic factors of influence included the clinicians’ personal traits and their perception about MI as a clinical priority. Organizational support was also a crucial extrinsic factor in encouraging the clinicians’ efforts.

Conclusion

As described in a fragmented manner in previous studies, MI implementation processes and influencing factors are presented as integrated findings. Incorporating engaging educational activities to provide clinicians with motivational support and collaborating with health care organizations to plan appropriate resources should be considered in the development of MI implementation programs from the onset.

Health care knowledge and technology have evolved at a rapid pace during the last decades, but an important gap persists between the care that is provided and that which would be recommended (Balas & Boren, 2000; Burnes, 2004), a phenomenon called the “quality chasm” (Institute of Medicine, 2014). Motivational interviewing (MI) is an evidence-based counseling approach that makes no exception to this phenomenon (Schwalbe et al., 2014).

MI uses a person-centered conversational style characterized by the MI spirit (collaboration, compassion, acceptance, evocation); the use of counseling skills (e.g., reflective listening, open questions, affirmations); and the application of the MI method (four processes including engagement, focalization, evocation, and planification) (Miller & Rollnick, 2013; Rollnick et al., 2022). Although MI is highly recommended in primary care (PC), most clinicians will never succeed in implementing the approach in everyday care (Brobeck et al., 2011; Graves et al., 2016; Midboe et al., 2011; Östlund et al., 2015). Feelings of discomfort and incompetence with the approach are commonly reported by newly trained PC clinicians (Brobeck et al., 2011; Midboe et al., 2011; Ӧstlund et al., 2015; Pfister-Minogue & Salveson, 2010; Pollak et al., 2016; Sargeant et al., 2008). Their insufficient training in counseling is stated as a possible explanation (Brobeck et al., 2011; Graves et al., 2016; Midboe et al., 2011; Ӧstlund et al., 2015). However, little is known about the underlying processes and influencing factors of MI implementation in PC failing to address this quality chasm (Schwalbe et al., 2014).

Therefore, this study aims to facilitate and describe PC clinicians’ professional transformation through interprofessional communities of practice on MI (ICP-MI). A community of practice brings together practitioners on an ongoing basis, sharing a common goal, namely to update their professional practices through peer support (Wenger et al., 2002). It is often supported by an external facilitator who has expertise in specific topics as in the field of continuing education (Wenger et al., 2002). For the study, the principal investigator (SL) provided a tailored MI training program of seven 3-hour meetings spread over nearly a year for each of the four investigated ICP-MIs, which involved four PC clinicians aiming at implementing MI in their workplace.

This article addresses the following research question:

• What are the MI implementation processes facilitated and observed within the ICP-MI as well as their influencing factors?

Other manuscripts in preparation will present the other results of the current study regarding the collective design of the training program and its impact on PC practice, in addition to a published article addressing the clinicians’ learning processes (Langlois & Goudreau, 2022).

Method

Research Design

Four ICP-MIs were investigated through participatory action research (PAR; Kemmis et al., 2014). The primary goal of PAR is to facilitate professional transformation by implementing tangible actions in the studied workplaces to overcome professional challenges. PAR bridges the gap between research and field, bringing together researchers and practitioners with the shared goal of furthering science and improving professional practice. To succeed in this endeavor, a cyclical process of reflection, planning, and action/observation is conducted until the co-participants, namely the researchers and the participating practitioners and/or deciders, are satisfied with the professional/organizational transformation (Kemmis et al., 2014).

The detailed methodology for this study was published (Langlois, Goudreau & Lalonde, 2014). In sum, this PAR included 10 cycles completed in collaboration with all co-participants (i.e., the principal investigator [SL], her doctoral supervisor [JG], and the 16 participating clinicians) for almost a year, as illustrated in Figure 1: PAR preparation (Cycles 1–2), PAR facilitation (Cycles 3–9), and PAR appraisal (Cycles 9–10).

Figure 1.

PAR Cyclical Process.

Note. PAR = participatory action research; PPP = preliminary planning phase; AOP = action/observation phase; RP = reflection phase; PP = planning phase; FMG = family medicine group.

Research Context and Intervention

The study took place in a suburban city near Montréal (Canada) and originated from a research program aiming to TRANSform InTerprofessional clinical practices to improve CVD prevention in primary care (TRANSIT). Patients, caregivers, clinicians, administrators, and researchers collaborated in identifying and investigating different priorities for action to improve chronic disease prevention in PC: MI training for PC clinicians was selected (Lalonde et al., 2014). Clinicians were then invited to an introductory 2-day training that was delivered by members of the MI Network of Trainers (MINT). Forty-five PC clinicians, including nurses, nutritionists, kinesiologists, pharmacists, family physicians, and psychologists, attended it. The study stems from TRANSIT research program to facilitate MI implementation following this introductory training and became an independent doctoral project which received ethical/scientific approval from the affiliated university and health care center (cycle 1).

All newly trained clinicians participating in the TRANSIT research program were invited to take part in this study. Sixteen PC clinicians were recruited, and four ICP-MIs were created. A preparatory meeting took place between each of the ICP-IM so that the co-participants could collaboratively establish the pedagogical and methodological choices of the study (Cycle 2).

During PAR facilitation (Cycles 3–9), seven meetings were conducted every 4 to 6 weeks followed by field experimentations conducted by the clinicians in their workplaces. Nineteen hours of MI learning/implementation support were delivered through various training activities based on workplace learning in continuing interprofessional education (Langlois, Goudreau & Lalonde, 2014; Kitto et al., 2012). ICP-MI meetings provided coaching and feedback opportunities and were all facilitated by the principal investigator (SL) who was a PC nurse trained in MI and in external facilitation of ICP. She also became an MINT member during the study.

During PAR appraisal, 12 clinicians participated in a focus group conducted within each ICP-MI (Cycles 9–10).

Clinicians’ Recruitment

Three inclusion criteria were determined to recruit the participating clinicians: (1) to participate in the TRANSIT research program as a PC clinician, (2) to have attended an introductory training on MI through TRANSIT or an equivalent in the past 2 years, and (3) to be available/interested to participate in an ICP-MI. Purposive sampling was used to recruit 16 clinicians from emails or in-person who provided written informed consent. Two clinicians dropped out of the study halfway for personal reasons.

Data Collection

Three qualitative data collection methods were used: a research journal throughout the study, participant observation of ICP-MI meetings during PAR facilitation, and focus groups during PAR appraisal.

Using a research journal is recommended in PAR to document the collective pedagogical/methodological decision-making process of the study (Kemmis et al., 2014). It also compiles field notes of observational methods and initiates qualitative data analysis (Pope & Mays, 2020). The research journal was accordingly used (Cycles 1–10), supporting all data collection and data analysis activities.

Participant observation is frequently used in PAR based on the collaborative nature of the research approach among the co-participants, namely researchers and practitioners/deciders (Kemmis et al., 2014). The researcher acts as the external facilitator, stimulating the practitioners’ reflections and resolutions from the unsatisfactory components of their professional practices while considering their workplace circumstances (Kemmis et al., 2014). In the study, the participant observation of 76 hours was completed during the seven meetings of the four ICP-MIs (Cycles 3–9), which were recorded and transcribed. This data collection method involved the principal investigator (SL) and the 16 participating clinicians.

A focus group facilitates discussions among participants who shared their experiences and triangulates perspectives regarding the studied phenomenon (Pope & Mays, 2020). In PAR, it encourages power sharing among the co-participants and facilitates the transformational process of this inquiry to overcome workplace challenges and organizational change through critical reflection and experiential learning (Chiu, 2003). A focus group of 45–60 minutes was co-facilitated by the principal investigator and an independent qualitative researcher after the last meeting of each ICP-MI (Cycle 9). A guide was elaborated to ensure consistency across groups and clarification of ambiguous or significant topics. Initially, the 12 participating clinicians provided a global appraisal of their implementation processes, followed by specific questions exploring their critical moments and specific challenges/facilitators regarding their professional/organizational transformation.

Data Analysis

A general inductive approach was completed during the data analysis (Thomas, 2006). This five-step approach is summarized in Table 1. It includes the immersion of the researchers in the raw data followed by data codification, segmentation, recontextualization, and conceptualization. This process was supported by the QDA-Miner software and involved all the authors. The participating clinicians contributed to the data analysis as research consultants, especially during the conceptualization of the research findings as recommended by Thomas (2006) and in PAR (Kemmis et al., 2014). Half of the clinicians who took part in the entire study (6) actively participated in this last activity of data analysis. During a 1-hour meeting, the principal investigator (SL) and her doctoral supervisor (JG) presented them with the preliminary results of the study and moderated discussions to collectively determine the final research findings. Data saturation was established during this meeting.

Table 1.

Inductive Process of Qualitative Data.

Five-step process of data analysis	Immersion in raw data	Codification	Segmentation	Recontextualization	Conceptualization
Description	Preliminary reading of transcripts	Text segmentation regarding the research objectives	Labeling the text segments to create the first categories	Deletion of redundant or similar categories	Creation of an integrating model illustrating the research findings
Segmentation targets	All documents		30–40 preliminary categories for each research question	15–20 intermediate categories for each research question	3–8 final categories for each research question
Data sources	Qualitative data collected through the research journal, participant observation of ICP-MI meetings, and focus groups.				Preliminary results contrasted to pre-existing theories and conceptual models
Triangulation	Principal investigator supported by her doctoral supervisor The clinicians acted as research consultants according to PAR methodology.				Collaborative validation of the research findings

Note. ICP-MI = interprofessional communities of practice on motivational interviewing; PAR = participatory action research.

Results

Clinicians’ Profiles

The clinicians’ profiles are detailed in Table 2.

Table 2.

Clinicians’ Profiles.

Profession Numbers of clinicians (gender)		Nutritionist 6 (6 F)	Nurse 5 (5 F)	Physician 2 (1 F,1 M)	Kinesiologist 2 (2 F)	Psychologist 1 (1 F)
Years of practice in primary care	0–15	4	2	—	1	—
	15–30	2	3	2	1	1
Years since first training on MI	0–2	4	5	2	—	1
	3–11	2	—	—	2	—
Years of MI use before the study	Never used MI	2	5	2	2	1
	0–2	4	—	—	—	—
	>2	—	—	—	—	—

Note. MI = motivational interviewing.

MI Implementation Processes

MI implementation was described as a motivational endeavor that was initially perceived as a terrifying challenge, which evolved into a professional revelation (Figure 2). Four processes were observed during the study by the co-participants: ambivalence, introspection, experimentation, and mobilization. Two categories of factors were also reported. The intrinsic factors involved the clinicians’ personal traits and their perception of MI as a clinical priority. The extrinsic factors related to organizational support and revealed to be crucial in providing appropriate resources while encouraging the clinicians’ efforts.

Figure 2.

The Motivational Endeavor of MI Implementation in PC

Note. The arrows in the middle of Figure 1 illustrate the evolutive processes of MI implementation with ambivalence about implementing MI in PC as a starting point. The clinicians then progressed toward professional introspection to realize MI implementation benefits to pursue with experimenting with MI implementation initiatives. Witnessing MI contribution to improve PC counseling practices, the clinicians were finally mobilized in actively implementing the approach in their counseling practices and workplaces. Two categories of influencing factors are described in the second circle as intrinsic (at top) and extrinsic (at bottom) factors. MI = motivational interviewing; PC = primary care.

Ambivalence

The processes of MI implementation began with a conflicting journey, according to the PC clinicians. As defined by Rollnick et al. (2022), ambivalence represents a person’s experience of simultaneously feeling two ways about changing one’s behavior. It is operationalized as expressions in favor of change (change talk), which often co-occur with expressions in favor of the status quo (sustain talk). MI was simultaneously perceived by the participating clinicians as a professional revelation considering its effectiveness and relevance in PC, but its implementation was perceived as utopian. Therefore, they were ambivalent to engage in MI implementation at the beginning of the study.

The two-day training [on MI] was a professional revelation! After that, when you go back to the field, in the real life, it takes so much time! “How am I going to do all of this?” You are searching for your words. You weigh everything you say. You feel like you must put on white gloves every time you speak. You are afraid of making a mistake! [MI implementation] is quite a puzzle. (CIL)

The clinicians’ ambivalence regarding MI implementation was described as a dilemma between the perceived relevance of the approach and the anticipated implementation challenges. The clinicians revealed that “[They] ended up doing what [they] always did” as “( . . .) the confidence in implementing MI was lacking” and “MI was out of reach. I thought it took too much time, too much energy.”

You can freeze by the lack of skills and confidence. A kind of terror sets in. People are panicking, uncomfortable applying MI. It’s been almost two years that we have been doing clinical discussions within my team to try to break down these barriers related to MI implementation. (CN)

Introspection

Eventually, this ambivalence progressed into a rich opportunity to conduct a professional introspection referring to a process of individual and collective reflection on the knowledge, attitudes, emotions, behaviors, and patterns involved in one’s professional practice.

Mid-project, the clinicians recognized the limitations of their previous directive interventions, which consolidated their motivation to pursue the MI implementation.

To be able to sit down and think about our practices, to see also what other clinicians think and do, it triggered a turning point for me. (BNJ)

I realized that what I thought I was doing well, but fundamentally it wasn’t the case. I realized that there were much better ways to intervene with patients and work with them to get results, to make changes. (DI)

Once a few clinicians shared their insights in that regard, rich and authentic discussions were encouraged among all the clinicians, who progressively engaged in an individual and collective reflective practice.

Our fears in implementing MI in our everyday practices, we named them. Our doubts also. Eventually, we weren’t afraid to put them on the table. And what was interesting when we talked about our doubts is that we were able to give each other feedback and support. It helped a lot to gain confidence to use MI bit by bit. (AN)

Experimentation

The experimentation process allowed clinicians to try and test their new MI knowledge and skills at ICP-MI meetings and in their daily practice to find out what impact it had on themselves and patients.

Gradually, bonds of trust and mutual support were consolidated during ICP-MI meetings, creating a constructive learning environment. Overcoming the “fears of being judged by peers,” the clinicians were ready to “make room for individual incompetence” as they engaged in practical exercises on MI while cultivating the “pleasure of learning.”

We took turns practicing one thing at a time. In this way, I see that I am learning and that she is also learning, we are experiencing the same difficulties. So that is motivating and reassuring to pursue with this training. (BI)

Over time, the initial “feeling of terror” dissipated, allowing clinicians to take on the challenge of implementing MI. At this stage, the process of experimentation evolved as the clinicians instigated MI implementation initiatives in their daily practice.

I think we see more the impact that MI has. We have the chance to work in a laboratory. Everyday! We are here on Tuesday evening and the next day, on Wednesday morning, we see patients. What a beautiful laboratory! This is precious! (AK)

I remember once using a little sentence that made an impact on a patient! It was like. . . he almost started to cry after I told him something that hit a nerve. I wasn’t used to intervening that way, it’s a new way of doing things for me. I realized “Wow, this is working!” (DI)

The first experimentations of the clinicians were discussed in ICP-MI, which highlighted the contribution of MI in improving PC practices. These successes motivated the others to overcome their ambivalence with MI implementation. Thus, by the end of the study, all clinicians were confident to use MI in their daily practice.

At first, I saw MI contribution through you, the experience you had with the approach and that you shared here [DI talking to DN]. For me, it always takes a little time before I change my habits. I watch, I listen. At one point, I tried MI with a patient, and I realized even more how well it works! (DI)

At the beginning of the training, I didn’t see how I was going to incorporate MI into my consultations. I was thinking “It’s too long!”. Finally, I see that we are more and more capable, and I realize that it does not take longer. It is even more effective and facilitating for us! (DN)

At one point, some clinicians felt confident enough to discuss and experiment with MI in challenging clinical situations.

Now I am more mindful of my interventions. With a difficult patient, I can prepare my interview [with the ICP-MI] to establish what I want to say and how I would use MI accordingly so that when I see that patient, I know where I want to go and how to go there. (AK)

Patients reluctant to change. . . Before, I didn’t know how to intervene to help them! I felt completely destabilized. I’ve learned here how to talk to these patients, how to get to them. (DI)

Mobilization

Mobilization was conceptualized by the co-participants as the process of bringing together different conditions that were needed to reach the purpose of the study, namely MI implementation.

Many of the clinicians proactively instigated various actions to ensure MI sustainability in their own practice, perceiving the approach as “making beautiful little miracles!”

I will complete a summary of everything I’ve learned: MI core ideas, the principal techniques. I would like to display it on my desk. It would be a way to remind me of MI concepts everyday. (AK)

Organizational change was also initiated as some clinicians planned diverse projects to promote MI in their workplace, thereby showing leadership among peers and decision-makers.

I borrowed one of our tools that we’ve discussed here, and I explained it to my team, even though some of the clinicians did not participate in this project. (. . .) When I say that MI implementation takes a lot of energy, it’s because you have to really want it to make it happen. In team meetings or an administrative committee, things go very quickly, and it must be a priority. For me, this is my number one priority as a manager. (CN)

I went to see my manager and I said to her: “The whole team must be trained in MI. We must use the same language.” And I had an impact. (BK)

Implementing MI: A Motivational Endeavor

Throughout the study, all the participating clinicians underlined the extent to which MI implementation required motivation. A parallel was established between MI implementation processes as facilitating professional behavior changes among PC clinicians and MI clinical processes facilitating health behavior changes among patients.

It’s like if we are the patients here. We must prepare ourselves before our meetings, we set our goals, we must practice and change our habits! And you [SL], you guide us through it all. (. . .) Changing our lifestyle, changing our professional practice, it’s pretty much the same and it takes time. (BI)

Table 3 presents the clinicians’ verbatim illustrating their motivational discourses which was analyzed according to MI concepts as sustain talk was preponderant during the first ICP-MI meetings which was followed by change talk at mid-project, evolving from preparatory to mobilizing change talk. “Sustain talk and change talk are conceptually opposite—the person’s arguments against and for change” (Miller & Rollnick, 2013, p. 165).

Table 3.

The Clinicians’ Evolutive Motivational Discourse About MI Implementation in PC.

Clinicians’ discourse	Sustain talk	Change talk
Preparatory talk
Desire to change	I ended up doing what I always did. (. . .) MI takes too much time, too much energy.	My interviews are more efficient, and it also requires less energy. Everything prompts me to continue.
Ability to change	Patients reluctant to change? Before, I didn’t know how to intervene! I felt completely destabilized.	I’ve learned here how to talk to these patients [reluctant to change their behaviors], how to get to them.
Reasons to change	It made me realize how I worked. (. . .) I thought I was doing well.	I realized that there was something that could greatly improve my relationship with patients and led to better outcomes.
Need to change	It would be so easy to realize that everything went out the window eventually!	MI implementation must be a priority. For me, this is my number one priority as a manager.
Mobilizing talk
Activation	I will do another training on MI. It seems a lot, but at the same time, I’m still in the thick of it. It’s not something I want to leave on the shelf.
Taking first steps	I remember once using a little sentence that made an impact on a patient! It was like. . . he almost started to cry after I told him something that hit a nerve. I wasn't used to intervene that way (. . .) I realized “Wow, this is working!”.
Commitment	Personally, I needed to set my own goals. If I don’t have a deadline. . . phew! “So there, I will focus on open questions by the next meeting.” Another time, it was the tool «Ask – Provide – Ask».

Note. The evolution of the clinicians’ motivational discourse throughout ICP-MI meetings about MI implementation is conceptualized according to Miller and Rollnick’s (2013) MI concepts. MI = motivational interviewing; PC = primary care.

Factors Influencing MI Implementation in PC

Intrinsic Factors

The clinicians’ personal traits were influential in perceiving MI implementation challenges as normal and stimulating or confronting and discouraging. Some clinicians perceived professional development as a lifelong learning project, which facilitated their MI implementation processes: “I leave our meetings, I don’t have complexes. Not at all. We don’t know everything in life and I’m 55, so I still have a lot to learn from life.” Others aimed for perfection: “MI is still new and the fear of not performing. . . It freezes me!” These participants took more time to overcome their initial ambivalence.

Presenting the readiness to transform practices was helpful in ICP-MI. Having developed personal and professional maturity was a favorable personal trait to implement MI in PC. In fact, only one clinician was in her 30s; all the others were more than 40 years old, with extensive clinical experience.

After 13 years as a dietitian, I felt like I was playing a tape, always saying the same thing over and over again. I wanted something else. (. . .) It’s also good that I was in my 40s and not my 20s! I can be easily insecure, and it was especially the case when I was younger. (BNJ)

The perception of MI as a clinical priority revealed itself to influence the clinicians’ disposition to change practices. A family physician exposed the challenges regarding MI implementation, as it competed with other clinical priorities. On the contrary, clinicians from other professions perceived health behavior change support as a cornerstone of their clinical approach.

When I see a patient, I have a series of priority topics to address in a given timeframe which leaves little time, even no time at all to provide counseling interventions. At all. (. . .) but it also happens that it is quite unidimensional and that I can take the time to provide MI. In a standard practice, however, it is not easy. (DM)

The bulk of my work, and I think for my colleagues from other professions as well, it’s motivation. People say that I do fitness programs. I say «No, I try to motivate people to move.» (AK)

Extrinsic Factors

The organizational support provided to the clinicians greatly influenced their MI implementation processes. Benefiting from local and organizational support motivated the clinicians to implement MI in their workplace.

In that regard, the collaboration of the colleagues to take over patient care or to plan health care services in their absence while attending ICP-MI meetings was varied.

As the researchers involved in TRANSIT are members of my healthcare team, we automatically believed in this study. We are part of several research projects, so it was very motivating for the team and me. (BI)

Today, there is nobody who takes over my work. And my colleagues complain about it. The doctors need to plan their work accordingly. Usually, I’m there all afternoon to help them, but now I won’t be there. So eight times, it’s a lot! (CIM)

Support from managers also encouraged the clinicians’ efforts in implementing MI within their own practices and to influence colleagues to follow suit.

Everyone on the team has had at least one day of MI training and I have a coordinator who is convinced of the relevance of MI. (. . .) It encourages me to implement it in my work so I may have less difficulty than others in the future because my work stimulates me in that regard. (AK)

Administrative support was determined during the PAR preparation to provide human, logistical, and financial resources. This gesture endorsed the clinicians’ venture as they felt “(. . .) extremely privileged to manage [their] agenda and be paid [for attending ICP-MI meetings].” In their daily practice, they also had “(. . .) the possibility to postpone topics that were addressed in other consultations, which took off some stress and left time for MI.” The clinicians working in a private practice deplored the lack of such an organizational support.

Of course, the time spent here is time that I’m not working. It’s time that I take for myself, for work. I really wanted to be here. I thought it was going to bring something, for me and for my patients. I wouldn’t have taken three hours every month for eight months otherwise! (BNJ)

Close to the end of the study, a vast project of MI diffusion was announced across the regional PC public services, which consolidated the clinicians’ motivation to pursue with MI implementation, but highlighted the specific challenge faced by self-employed clinicians.

MI is actually popular, even across Québec, but what I believe will help us a lot is that there is a three-year project that will be launched soon by the organization. We are starting another wave of MI training so there will be more and more people trained. MI will be used more and more across our territory. (CIM)

The context is not as facilitating in private practice. There’s no supportive environment. At least here, there were people involved, there were our meetings. How to maintain this momentum and continue to implement MI in my practice? It can be done, but it will require strategies! (AN)

Discussion

The contextualization of our findings was guided by the Consolidated Framework for Implementation Research (CFIR). This framework presents five domains in implementing health care innovations according to (1) the characteristics of the intervention to be implemented, (2) the individual factors specific to the people involved, (3) the internal and (4) external contextual factors of the targeted health care settings, and (5) the conduct of implementation processes, including planning, engaging, executing, and reflecting/evaluating (Damschroder et al., 2009). This study presents an overview of the second to fifth domain involved in MI implementation processes, namely, (2) the clinicians’ personal traits and their perception of MI as a clinical priority; (3) the local and (4) regional organizational support provided by the public health care system, which was missing for those clinicians working in private practice; and (5) the implementation phases guided by the PAR cyclical process. Damschroder and colleagues (2009) emphasized the lack of research on the intrinsic factors influencing the implementation of health care innovations and the frequent omission of engaging activities within the implementation process. This study specifically addresses these knowledge gaps and contributes through its thorough description of clinicians’ motivational endeavor in implementing MI within PC, as experienced and analyzed by the co-participants.

To our knowledge, no studies have documented through PAR the MI implementation processes experienced by PC clinicians. However, a few researchers have looked at the perspectives of clinicians implementing MI within PC who underlined the underestimated importance of evoking the limitations of previous authoritarian counseling approaches to engage PC clinicians early in MI training programs (Brobeck et al., 2011; Pfister-Minogue & Salveson, 2010; Östlund et al., 2015). As presented during this study, Pfister-Minogue and Salveson (2010) describe the contribution of professional introspection of PC clinicians’ practices to support their awareness of the possible dissonance between their actual and desired counseling approach to progress toward MI implementation. Therefore, our findings suggest a new and integrated empirical perspective through four MI implementation processes—ambivalence, introspection, experimentation, and mobilization. These processes were related to the MI method in exploring and resolving ambivalence by reflecting on and evoking intrinsic motivations to facilitate behavioral changes. Future studies would gain from delving deeper into these findings to clarify how MI training programs could consolidate their engaging activities accordingly.

As for the clinicians’ intrinsic factors, the influence of the clinicians’ personal traits and their personal/professional maturity were reported in this study as well as in the existing literature. Different authors suggest that presenting a positive attitude and self-confidence to transform clinical practices (Brobeck et al., 2011; Graves et al., 2016; Östlund et al., 2015) as well as having extensive professional experience (Brobeck et al., 2011; Ӧstlund et al., 2015) would help clinicians implementing MI in PC. These clinicians would be more inclined to conduct reflective practice activities to succeed in MI implementation compared with their colleagues (Brobeck et al., 2011; Ӧstlund et al., 2015). A meta-analysis has also reported that clinicians, who presented a minimum of 5 years of clinical practice, typically benefit more from MI training compared with their peers who are recent graduates (Schwalbe et al., 2014). Regarding the influence of the different clinicians’ perspectives on MI as a clinical priority, which was another intrinsic factor that our study presented as possibly impacting MI implementation in PC, our literature review did not uncover any data on this topic. The small number of clinicians who took part in the study prevents us from drawing any generalizations. Further research using an interdisciplinary perspective is encouraged to clarify the impact of this individual factor.

As for extrinsic factors, the study underlined the central influence of organizational support. In the same line of thoughts, Brobeck et al. (2011), Graves et al. (2016) and Östlund et al., (2015) reveal that promoting a culture of continuing education and person-centered care would facilitate MI implementation initiatives within PC. These authors also underline the impact of providing appropriate resources which avoid work overload as an important barrier to extensive MI training. The contribution of peer support was also documented in past research as playing a key role in sharing implementation strategies in the workplace (Graves et al., 2016; Ӧstlund et al., 2015). The context of private practice as an influential factor of MI implementation in PC was absent from our literature review and constitutes an interesting topic to elucidate in future studies.

This PAR presents methodological strengths and limitations. The clinicians’ contributions throughout the research process were notable, although they partially contributed to data analysis and dissemination of research findings as decisions jointly taken among the co-participants. Another limitation relates to the limited transferability of findings, considering the favorable context of this PAR such as the significant commitment of the principal investigator who facilitated the ICP-MI meetings and the selection bias of the participating clinicians. A sense of ambivalence regarding MI implementation was nevertheless observed, which underlines the relevance of anticipating the challenges described earlier. Finally, the study did not include patients and administrators, whose perspectives about MI implementation in PC would be interesting to detail in further inquiries.

In sum, MI implementation within PC remains an understudied domain. To our knowledge, no study has previously described its underlying processes and influencing factors through the unique lens of PAR. Innovative findings are thus presented, including the crucial role that motivation plays to engage clinicians in their professional development on MI.