Abstract
Objective
This study explored chiropractic students’ self-reported understanding and attitudes regarding motivational interviewing (MI), and examined the relationship between students’ patient-centered communication (PCC)-related attitudes and beliefs and intent to use MI.
Methods
An explanatory sequential mixed methods study was conducted with full-time chiropractic students enrolled across 7 North American doctor of chiropractic degree programs. Eligible students completed an online survey; descriptive statistics and logistic regression were used to examine the relationship between PCC-related attitudes and beliefs and intent to use MI. Following the survey, students were invited to participate in virtual interviews; qualitative data were analyzed using thematic analysis.
Results
Of the 426 survey respondents (7% response rate), most reported completing PCC-related coursework (75.85%). While 69.73% reported understanding MI principles, only 13.51% felt proficient in its use. Over half (53.25%) intended to use MI, yet many endorsed beliefs misaligned with MI principles. The mean PCC-related attitudes and beliefs score was 143.39 (SD 18.42). Higher PCC-related attitudes and beliefs was significantly associated with greater odds of intent to use MI (odds ratio 1.03 [1.01–1.04], P < .001). Qualitative data responses reflected positivity toward MI, inconsistent exposure and training in MI, and student viewpoints that may be inconsistent with the spirit of MI.
Conclusion
This study contributes toward the understanding of North American chiropractic students’ understanding of MI and its relationship with PCC-related attitudes and beliefs. Further research is needed to investigate how MI is introduced, taught, and longitudinally supported within chiropractic education programs.
Keywords: Motivational Interviewing, Chiropractic, Students, Education
INTRODUCTION
Current clinical practice guidelines emphasize a whole-person approach to managing low back pain (LBP), including a multimodal, patient-centered model of care.1,2 This multimodal, patient-centered approach incorporates biopsychosocial (BPS) principles.3 A patient-centered, BPS approach to care involves active patient engagement that addresses the confluence of biological (eg, age, genetics), psychological (eg, beliefs, behavior), and social factors (eg, social support, socioeconomic status) that may influence a person’s lived experience.3 The lifetime prevalence of LBP is estimated to be as high as 84%, with an annual prevalence estimated to be as high as 65%.4 LBP is also the leading cause of years lived with disability worldwide, underscoring its substantial public health impact.5,6 Given its widespread prevalence and impact, ongoing research efforts are needed to optimize management strategies.
Research highlights the role of patient-centered communication (PCC) strategies, such as motivational interviewing (MI),7,8 in the management of spine pain. MI is a collaborative, goal-oriented approach designed to empower individuals in self-discovery while fostering an environment of acceptance and compassion.9 This collaborative approach between the patient and the clinician differs from other behavioral modification approaches that employ a doctor-led approach. MI aligns with BPS principles of patient-centered care by eliciting patient values, beliefs, social context, and readiness for change to guide management strategies. Additionally, other PCC constructs, such as empathy and cultural humility are likely to inform clinician communication and may enhance the effectiveness of MI.10,11 Evidence suggests that MI can enhance patient outcomes, including improvement in quality of life, self-efficacy, and treatment engagement.12,13 PCC, including the use of MI as a communication tool, is dependent on clinicians’ understanding, attitudes, and intent to use this skill in practice. Despite its presence in mainstream health care,14–16 the integration of MI into health professions education—particularly education focused on pain management and the musculoskeletal system—remains underexplored.17
A significant portion of adults seek chiropractic care for spine pain, with a 2015 US national survey estimating that 1 in 4 adults sought chiropractic care for spine pain.18 Chiropractors have traditionally embraced a whole-person approach, incorporating BPS principles into patient care.19,20 Despite the holistic foundation of chiropractic care and the BPS approach, there is a paucity of research exploring the landscape of PCC, particularly MI, in chiropractic education and practice.
This study primarily aimed to explore chiropractic students’ self-reported understanding and attitudes regarding MI. The secondary aim was to explore the relationship between chiropractic students’ PCC-related attitudes and beliefs and intent to use MI.
METHODS
Study Design, Target Population, and Recruitment
This study was an explanatory sequential mixed methods study using both quantitative and qualitative methods.21 A cross-sectional survey was first administered to evaluate chiropractic students’ self-reported PCC-related attitudes and beliefs, and their understanding, attitudes, and intent to use MI in their work. To further understand and explain survey findings, 1 focus group and 1 semistructured interview were conducted with a subsample of participants who completed the survey. No incentives were provided for participation in the survey or focus group and semistructured interview. This study was reported according to the Strengthening the Reporting of Observational Studies in Epidemiology guidelines.22 Institutional Review Board approval was obtained (Medical College of Wisconsin [MCW]: PRO00052669).
The target population was chiropractic students enrolled full-time in one of the following doctor of chiropractic degree programs (DCP) in North America: Canadian Memorial Chiropractic College, Life Chiropractic College West, Northeast College of Health Sciences, Northwestern University of Health Sciences, Parker University, Palmer College of Chiropractic (Florida and Iowa campuses), and University of Western States. Eligibility criteria included current full-time enrollment in a participating DCP. Eligible chiropractic students (n = 6076) were invited to participate in an electronic survey via email. An email invitation was sent from the primary investigators at MCW to a collaborator at each participating DCP in this study. Purposive sampling was used to identify organizational collaborators, who subsequently disseminated the survey within their organizations. The collaborators at each respective DCP forwarded the email invitation to all eligible chiropractic students at their respective DCP. The survey was distributed beginning on January 21, 2025, with 2 reminder emails distributed in 1-week intervals by the same process. The survey was closed on March 5, 2025.
Participants who completed the online survey were asked if they would be interested in being contacted to complete a subsequent virtual interview session. The focus group and semistructured interview were completed between March 24, 2025, and May 15, 2025.
Survey
The electronic survey was administered via Qualtrics (Qualtrics LLC)23 and hosted by MCW. The study details and an informed consent statement were included on the first page of the survey link, requiring these documents to be reviewed and acknowledged prior to beginning the survey. The first section of the survey collected demographic information, including age, gender, race, pre-DCP enrollment education level, DCP enrollment status, PCC-related coursework completion in DCP, and PCC-related attitudes and beliefs. We defined DCP enrollment status as either preclinical or clinical. Preclinical status was defined as “the early stage of your curriculum where your primary focus is foundational sciences such as anatomy, physiology, biochemistry, and pathology. Most of your time is spent during this phase without direct patient interaction.” Clinical status was defined as “the later stage of the program where you apply your pre-clinical knowledge in real-world settings. It involves hands-on experience with patients in clinical environments like hospitals/clinics, under the supervision of licensed professionals.” Participants were asked to record their DCP during data collection; however, these data were not reported to maintain confidentiality.
The second section of the survey included items related to predisposition for empathy using the revised Kiersma-Chen Empathy Scale (KCES-R) and predisposition for cultural humility using the Foronda’s Cultural Humility Scale (FCHS). The KCES-R, developed from the original Kiersma-Chen Empathy Scale to assess empathy in allied health professions students, consists of 14 items divided into 2 separate sections.24 The first section of the KCES-R assessed global empathy with 7 response categories (1 = unnecessary to 7 = extremely necessary), while the second section assessed self-perception of empathy using 7 response categories (1 = does not describe me to 7 = describes me extremely well).24 Typical scores range from 15 to 105, with higher scores indicating greater empathy.24 The use of the KCES-R for this study was obtained from its founders. Of note, the KCES-R has published validity evidence with nursing and pharmacy students; however, further validation in other health professions education is needed.24,25 Students’ predisposition for cultural humility was explored using FCHS. The FCHS was determined reliable (Cronbach α = .85) to assess cultural humility in health professions students.26 The FCHS is a 19-item survey using a Likert scale (0 = none of the time to 5 = all the time) with scores typically ranging from 19 to 95. Scores are categorized as follows: 19–38 (“Rarely Culturally Humble”), 39–75 (“Sometimes Culturally Humble”), 76–85 (“Usually Culturally Humble”), 86–95 (“Habitually Culturally Humble”), with higher scores indicating greater cultural humility.26
The third section of the survey included items related to understanding, attitudes, and intended use of MI. To our knowledge, no validated tool currently exists to measure understanding, attitudes, and intended use of MI. Existing validated tools, such as the Motivational Interviewing Treatment Integrity Code27 primarily assess skill performance rather than the constructs related to this study. Therefore, we adapted this section of the survey from an instrument originally developed for a formal evaluation of MI training in a professional context.28 This included 13 items, with each item allowed for 1 response on a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree).
Statistical Analysis
Statistical analysis was completed using STATA version 15.1 (StataCorp). Descriptive statistics were calculated for all variables, including demographic variables. Continuous variables were calculated as mean with SD. Categorical variables were calculated as percentages.
A composite variable representing PCC-related attitudes and beliefs was created by summing the total scores of the KCES-R (empathy) and the total scores of the FCHS (cultural humility). This approach was informed by prior research demonstrating a relationship between empathy and cultural humility.29 These constructs have been shown to concurrently inform clinician communication behaviors and orientation to care, therefore, the composite score was intended to capture a broader measure of PCC-related attitudes and beliefs.29,30 Potential scores for the composite PCC-related attitudes and beliefs variable ranged between 15 and 200. Higher scores indicated higher PCC-related attitudes and beliefs. Because KCES-R and FCHS have not been used within our target population, the correlation between KCES-R (empathy) and FCHS (humility) scores was assessed using Pearson correlation coefficient. Ninety-five percent confidence intervals for the correlation were calculated using Fisher z transformation. Given nonnormal score distributions, Spearman rank correlation coefficient was also calculated. Descriptive statistics (mean and SD) were also calculated for the composite PCC-related attitudes and beliefs variable.
Because the MI items were adapted from a prior professional-training instrument used outside of our target population, internal reliability was evaluated using Cronbach α. Exploratory factor analysis was used to examine dimensionality of the MI items.
Logistic regression was used to explore the association between participants’ PCC-related attitudes and beliefs and the intent to use MI in their work. For purposes of the logistic regression, we collapsed the intent to use MI variable to 2 categories: 1) “more likely” (Strongly Agree, Agree), and 2) “less likely” (Strongly Disagree, Disagree, Neutral).29 The independent/predictor variable was PCC-related attitudes and beliefs. The dependent/outcome variable was intent to use MI in their work. We controlled for demographic variables to account for participant heterogeneity and the potential relationship to outcomes.29,31 Demographic covariates included: age, gender, race, pre-DCP matriculation education level, DCP enrollment status (preclinical or clinical), and PCC-related coursework completion in DCP.
Focus Group and Semistructured Interview
All survey respondents were given the option to indicate their interest in a follow-up interview. A subsample of survey participants who reported interest in participating in a subsequent interview session were invited by email to participate in focus group and semistructured interview sessions. An informational letter for the interview participation was included in the invitation email. All individuals who expressed interest were invited by a research coordinator, ensuring that the authors remained blinded to identifying participant information and thereby reducing potential bias in the recruitment process. The subsample of participants were purposefully recruited from the larger sample to obtain diverse student characteristics (eg, program enrollment, preclinical vs clinical, gender, age, race). The goal was to include participants with varied demographic and educational characteristics to capture diverse perspectives rather than achieve representativeness. Four participants completed interviews due to voluntary participation and scheduling limitations.
The virtual focus group and semistructured interview were hosted by MCW using Microsoft Teams. Interviews were conducted by 2 investigators (JAG and ALJ). Interviews lasted between 45–60 minutes in length. We used a semistructured interview guide that allowed for flexibility for the interviewer to prompt and further expand on follow-up questions for a more in-depth dialogue. The guide covered topics including: 1) Experiences with chiropractic education specific to PCC, 2) Perceptions of facilitators and barriers that exist in the chiropractic educational landscape regarding the acquisition and use of patient-centered care and communication, 3) Perceived relevance of approaching patient care through a lens of empathy, cultural humility, and MI. The focus group and semistructured interview were recorded via Microsoft Teams to allow transcription by ALJ.
Qualitative Data Analysis
We used an inductive approach to data analysis using thematic analysis according to Braun and Clarke.32 The focus group and semistructured interview transcripts were analyzed and coded by 2 members of the study team (ALJ and DT). We began with open coding to create an initial codebook that was applied to the entirety of both transcripts. Potential themes were identified from codes and data were sorted according to potential themes. Themes were iteratively reviewed and refined until themes were named and defined. Given the small number of participants (n = 4), the qualitative component was intended to be exploratory and to potentially provide context for the quantitative survey findings rather than to achieve thematic saturation or generalizable conclusions.
RESULTS
Demographics
A total of 426 participant responses were collected out of a total of 6,076 eligible, full-time chiropractic students who were invited to participate (7% response rate). Table 1 describes demographic characteristics of participants. Over half of the participants identified as a woman (59.7%). The majority of participants identified as White (80.7%) and reported a bachelor’s degree or less as their highest level of education prior to matriculation in a DCP (93.8%). Over half of the participants reported being in the preclinical stage (61.3%). The remaining 38.7% of participants were in the clinical stage at their respective DCP curriculum. The majority of participants reported completion of PCC-related coursework within their respective DCP including empathy, cultural humility, or MI (75.8%). The mean score of participants “PCC-related attitudes and beliefs” score (sum of empathy and cultural humility) was 143.39 (SD = 18.42), with scores ranging from 56 to 174 (possible range: 34–200).
Table 1.
Descriptive Statistics for Participant Characteristics
| Demographics | N (%) or Mean (SD) |
|---|---|
| Age | |
| 18–25 years | 277 (65.02) |
| 26–35 years | 121 (28.40) |
| ≥36 years | 28 (6.57) |
| Gender | |
| Woman | 252 (59.72) |
| Man | 170 (40.28) |
| Race | |
| White | 338 (80.67) |
| Asian | 26 (6.21) |
| Black/African American | 14 (3.34) |
| Latinx | 24 (5.73) |
| Other | 17 (4.06) |
| Education | |
| Undergraduate degree or less | 387 (93.85) |
| Graduate/professional degree | 26 (6.15) |
| Enrollment status | |
| Preclinical | 261 (61.27) |
| Clinical | 165 (38.73) |
| PCC-related coursework completion | |
| No | 100 (24.15) |
| Yes | 314 (75.85) |
| PCC-related attitudes and beliefsa | 143.39 (18.42) |
Patient-centered communication (PCC)-related attitudes and beliefs is a composite score calculated by summing the total scores from the Kiersma-Chen Empathy Scale (KCES-R) and the Foronda’s Cultural Humility Scale (FCHS).
Knowledge, Attitudes, and Intended Use of MI
Table 2 describes the responses to the MI-related survey items. The majority of participants agreed or strongly agreed (69.7%) that they had an understanding of the basic principles of MI. Few participants agreed or strongly agreed (13.5%) that they felt proficient in the use of MI. Most participants agreed or strongly agreed (83.8%) that there was limited administrative support for integrating MI into their work.
Table 2.
Descriptive Statistics for Motivational Interviewing (MI) Questions
| MI Questionnaire | Strongly Disagree (%) | Disagree (%) | Neutral (%) | Agree (%) | Strong Agree (%) |
|---|---|---|---|---|---|
| I understand the basic ideas and principles of MI. | 4 (1.08) | 24 (6.49) | 84 (22.70) | 179 (48.38) | 79 (21.35) |
| I feel proficient and able to use MI in practice. | 41 (11.08) | 205 (55.41) | 74 (20.00) | 38 (10.27) | 12 (3.24) |
| Lack of motivation for change is a significant frustration for my patients. | 16 (4.32) | 81 (21.89) | 219 (59.19) | 41 (11.08) | 13 (3.51) |
| My patients’ lack of motivation for change is a significant frustration in my work. | 1 (0.27) | 6 (1.62) | 96 (25.95) | 161 (43.51) | 106 (28.65) |
| I believe that a patient’s own level of motivation for change is important. | 0 | 2 (0.54) | 39 (10.54) | 177 (47.84) | 152 (41.08) |
| If a patient is not initially motivated, I do not think that I will be able to increase their motivation. | 4 (1.08) | 10 (2.70) | 126 (34.05) | 143 (38.65) | 87 (23.51) |
| There is limited administrative support for integrating MI into my work. | 0 | 5 (1.35) | 55 (14.86) | 178 (48.11) | 132 (35.68) |
| MI is applicable to my work. | 34 (9.19) | 75 (20.27) | 144 (38.92) | 97 (26.22) | 20 (5.41) |
| I am a skillful good listener in working with patients. | 17 (4.59) | 51 (13.78) | 94 (25.41) | 154 (41.62) | 54 (14.59) |
| I will use MI in my work. | 10 (2.70) | 48 (12.97) | 115 (31.08) | 139 (37.57) | 58 (15.68) |
| I think that the most effective way to motivate patients to change is by drawing on their own internal motivations. | 11 (2.97) | 35 (9.46) | 182 (49.19) | 110 (29.73) | 32 (8.65) |
| Some patients need to be coerced or pressured to change. | 7 (1.89) | 44 (11.89) | 174 (47.03) | 107 (28.92) | 38 (10.27) |
| Some patients will never change regardless of how I interact with them. | 0 | 2 (0.54) | 26 (7.03) | 122 (32.97) | 220 (59.46) |
The majority of participants agreed or strongly agreed (88.92%) that a patient’s own level of motivation for change is important. However, many also indicated that if a patient is not initially motivated, they do not think that they [clinician] will be able to increase their [patient] motivation (62.2% agreed or strongly agreed). Furthermore, some participants agreed or strongly agreed (39.2%) that some patients need to be coerced or pressured to change, and a significant majority agreed or strongly agreed (92.4%) that “some patients will never change regardless of how I interact with them”. Some participants agreed or strongly agreed (31.6%) that MI is applicable to their work, while just over half of participants agreed or strongly agreed (53.2%) that they will use MI in their work.
Psychometric Testing
KCES-R (empathy) and FCHS (humility) were positively correlated (Pearson r = 0.580 [95% CI: .508–.643], P < .001; n = 373). Results were similar using Spearman rank correlation (rho = 0.615, P < .001).
The 13 MI items used in this study demonstrated modest overall internal reliability (Cronbach α = 0.63). Exploratory factor analysis supported a 2-factor structure. Internal consistency was higher for 1 factor-derived subscale (7 items; α = 0.81) and modest for the second subscale (6 items; α = 0.63).
Regression Analysis
Results of the adjusted logistic regression model examining the relationship between PCC-related attitudes and beliefs and intent to use MI are presented in Table 3. After adjusting for demographic covariates, participants PCC-related attitudes and beliefs was significantly associated with higher odds of intent to use MI in their work (OR = 1.03 [1.01–1.04], P = <.001).
Table 3.
Logistic Regression Exploring the Relationship Between PCC-related Attitudes and Beliefs and Intent to Use Motivational Interviewing (MI)
| Variable | β Coefficient | Odds Ratio (OR) [95% CI] | P value |
|---|---|---|---|
| PCC-related attitudes and beliefs | 0.027 | 1.03 [1.01–1.04] | <.001 |
| Enrollment (Ref: Preclinical) | |||
| Clinical | 0.198 | 1.22 [0.75–1.97] | .420 |
| Age (Ref: 18–25 years) | |||
| 26–35 years | −0.129 | 0.88 [0.51–1.50] | .637 |
| ≥36 years | 1.653 | 5.23 [1.68–16.27] | .004 |
| Gender (Ref: Woman) | |||
| Man | 0.050 | 1.05 [0.65–1.70] | .837 |
| Race (Ref: White) | |||
| Asian | −0.055 | 0.95 [0.37–2.43] | .909 |
| Black/African American | 0.682 | 1.98 [0.35–11.17] | .440 |
| Latinx | −0.020 | 0.98 [0.37–2.58] | .967 |
| Other | 0.250 | 1.29 [0.41–4.01] | .666 |
| Education (Ref: Undergraduate or less) | |||
| Graduate or professional degree | −0.134 | 0.87 [0.33–2.29] | .785 |
| PCC-related coursework completion (Ref: No) | |||
| Yes | 1.041 | 2.83 [1.63–4.94] | <.001 |
CI = confidence interval; PCC = patient-centered communication.
Qualitative Thematic Analysis
One focus group (n = 3 participants) and 1 semistructured interview were conducted (n = 1 participant). Of the 4 participants, 2 identified as a woman, all reported a bachelor’s degree or less as their highest level of education prior to matriculation in a DCP, 2 reported being in the preclinical stage, and 3 reported completion of PCC-related coursework within their respective DCP. Three themes were developed from the qualitative analysis: 1) Chiropractic students expressed positive attitudes toward MI, viewing it as a valuable component of patient encounters, 2) There was inconsistent exposure and training in MI across DCPs that chiropractic students attended, 3) Chiropractic students expressed viewpoints that may be inconsistent with the spirit of MI. Across the focus group and semistructured interview, participants frequently described MI as a valuable communication tool for engaging patients in their care. While many participants expressed positive attitudes towards MI, their reported exposure to MI varied considerably. Despite the widespread positivity, participant also shared comments that reflected beliefs and approaches that diverged from MI’s foundational principles, suggesting a potential disconnect between perceived understanding and alignment with the spirit of MI.
For theme 1, participants described MI as a valuable tool for patient interactions, particularly in promoting self-efficacy, empowerment, and behavior change. They discussed how the use of MI may enhance patient involvement in their care plan. They also reflected that engaging in the use of MI may help build empathy over time. One participant shared their positive attitude towards MI, noting “I love motivational interviewing. This is one of my favorite things ever. You get to see people that maybe don’t feel so empowered become empowered about themselves. Peoples’ self-esteem grows.”
Theme 2 identified there was inconsistent exposure and training in MI across DCPs that chiropractic students attended. Participants described varying levels of exposure and training in MI across their respective DCPs. All participants described some level of exposure to MI prior to matriculation in their DCP. Participants early on in their education, noted that they had not yet received formal instruction in MI but had positive experiences with MI-informed approaches during visits to the student clinic. Other participants reported that MI was not included in their curriculum at all, highlighting potential inconsistency in how MI may be emphasized across DCPs. One participant noted “We have not come across it and its not in any of our curriculum… from the semesters I’ve had and the semesters going forward, it’s not been incorporated at all.”
For theme 3, throughout the focus group and semistructured interview, participants described viewpoints inconsistent with MI principles. The concept of patient compliance was a recurring topic. Some participants described MI as a strategy to obtain patient buy-in, while others framed it in a way that suggested more “forceful” approaches may be necessary. These descriptions reflect a potential misinterpretation of MI principles.
One participant described a hypothetical clinical encounter that involved an ultimatum about imaging, which they considered a nontraditional approach to MI:
“And sometimes you need to pull that out and say hey I understand that you really don’t want to go get an X-ray, but you need to go get an X-ray because such and such risk factors… I will not treat you unless you get imaged and give them that ultimatum. Kind of… make that happen… I would argue that that’s kind of a motivational interview strategy as well, even though it’s less traditional, get patient buy in, sometimes you have to be a little more forceful with it.”
DISCUSSION
This multisite survey was exploratory in nature and aimed to generate preliminary insights into the current landscape of MI within a sample of North American DCP students. Our findings suggest that students in this study who report greater PCC-related attitudes and beliefs are more likely to report intent to use of MI in their work. Additionally, our findings suggest that within this sample, there was potential disconnect relating to the understanding of basic MI principles.
Approximately 54% of the participants agreed or strongly agreed that they will use MI in their work. In comparison, Ekong et al29 observed that 74% of pharmacy students intend to use MI in clinical practice following a short educational session on MI. It is important to note that most studies within allied health fields explore the intent to use MI following educational sessions, showing a subsequent increase in the confidence and knowledge of MI.33–35 While dissimilar, yet conceptually relevant, our findings suggest that there was a significant association between prior PCC-related coursework and intent to use MI. However, our findings suggest that few participants agreed or strongly agreed that they felt proficient in the use of MI. Given the established link between education, confidence, and intent to use MI, future studies could explore how integrating MI into chiropractic coursework influences students’ proficiency.
While self-reported understanding of MI was high, this was contrasted by responses suggesting potential misunderstandings about MI principles regarding behavior change. Interestingly, most participants agreed or strongly agreed with the statement that some patients will never change regardless of how I [provider] interact with them [patient]. This perspective stands in contrast to one of the foundational principles of MI, the belief that change is possible and that provider communication plays a meaningful role in evoking change behaviors.36 Additionally, nearly 40% of participants agreed or strongly agreed that some patients need to be coerced or pressured to change. This theme was also reflected in the qualitative data, where participants described using “forceful” strategies to achieve “patient buy-in”, yet still framed it as MI. This perspective is also inconsistent with the “spirit” of MI, which emphasizes patient autonomy, collaboration, and evocation rather than persuasion or pressure.36 MI is grounded in the idea that change arises from the patient’s own motivation, and that providers may serve as a resource to help identify and facilitate internal motivation.37 While most participants endorsed an understanding of the basic principles of MI, these results may suggest a potential disconnect between students self-reported understanding of MI and their actual understanding of MI principles. Moreover, these findings may highlight a potential gap in students’ understanding of how to guide patients towards change, and this perceived disconnect may help explain why most students did not feel proficient in MI.
In this study, PCC-related attitudes and beliefs included empathy and cultural humility. Empathy has been identified as a core principle of the “spirit” of MI,38 and higher levels of empathy have been associated with higher quality and effectiveness of MI.10 Additionally, recent research has explored the integration of cultural considerations into MI approaches,39 suggesting that cultural consideration may improve the effectiveness of MI in diverse patient populations.11 While our study examined self-reported intent to use MI rather than actual behaviors or outcomes, the observed associations are interestingly aligned with existing literature that emphasizes the importance of empathy and cultural considerations in MI. Notably, much of the current literature has focused on the impact of empathy and cultural humility on the effectiveness of MI approaches. Whereas our findings speak more to students’ attitudes and beliefs surrounding these values. The complex relationship between PCC-related attitudes and beliefs, and outcomes is challenging to disentangle.
For example, students’ reported predisposition towards empathy, cultural humility, and intent to use MI may be viewed not as fixed traits, but as fluid dispositions, shaped by socialization including institutional culture, prior lived experiences, and broader cultural understanding. Therefore, our findings should be interpreted with caution, as they reflect self-reported attitudes rather than observed behavior or outcomes. Future research may explore how chiropractic students’ predispositions, particularly their orientation towards empathy, cultural humility, and MI, influence the application of and effectiveness of MI in practice.
Lastly, most participants reported limited administrative support for integrating MI into their work. Because “work” may have been interpreted differently by preclinical and clinical students (eg, coursework vs patient care), this finding should be interpreted cautiously. While the survey did not clarify what “administrative support” referred to, such as curricular emphasis or clinical structure, this response may suggest a perceived lack of institutional support of MI within a DCP. Interestingly, 1 participant in the qualitative phase described perceived “bureaucratic support” for the use of MI at their DCP. Nonetheless, without additional context, this finding should be interpreted cautiously. Future research may be valuable in further exploring what students perceive as barriers to implementation of MI into their work. Although age was not a primary construct of interest, we observed a statistically significant association between older age and intent to use MI. This may represent a potential direction for future research to explore how student characteristics and curricular coursework influence engagement with MI.
While many students reported an understanding of MI, there appeared to be inconsistencies between self-assessed knowledge and alignment with MI principles. This disconnect may reflect limited exposure to MI within chiropractic curricula. As effective patient communication becomes increasingly central to health care delivery, integrating structured, longitudinal MI training into chiropractic education may support skill development.
Future Studies
Future research could examine how curricular inclusion of MI influences student confidence, proficiency, and long-term clinical application.
Strengths
One of the strengths of this study was the use of the validated KCES-R and FCHS for assessing the respondents’ predisposition for empathy and cultural humility, respectively. While these instruments have not been used specifically in chiropractic students, they have been validated in other health professions populations. Use of these respected instruments provided a stronger measure of the variables than if we had used a novel instrument.
Limitations
This study has several limitations. First, the low response rate is a notable limitation to the generalizability of these findings, as we could not determine sample representativeness due to the lack of demographic data across DCPs. Moreover, the reliance on self-reported data introduces the risk for response bias and may not fully represent student understanding or intent to use MI. The MI survey items were adapted from an instrument used in a professional training context, and while many items were applicable, some may not fully align with an educational setting. In addition, preliminary psychometric testing of the MI questionnaire suggests modest internal reliability. Therefore, results should be interpreted cautiously. Future research exploring MI in chiropractic education may need to consider the context of instrument selection, including whether validated MI tools or further adapted self-report measures are most appropriate. Because only full-time students were eligible to participate, perspectives of part-time or nontraditional students were not captured. Future research may consider including these groups, as factors associated with these groups (eg, such as socioeconomic status) may affect empathy and cultural humility perspectives. Additionally, the study included only a subset of North American DCPs, which may not fully capture the broader landscape of MI in chiropractic education. Finally, the qualitative data were drawn from a small subset of participants, limiting a full representation of chiropractic students in this study.
CONCLUSIONS
This study explored the landscape of MI within a subset of North American DCP students. The majority of survey participants indicated they had basic knowledge in MI, though fewer participants felt proficient in the use of MI. Our data suggest a potential disconnect between perceived understanding of MI and alignment with its core principles. Additionally, we observed an association between PCC-related attitudes and beliefs and intent to use MI in practice. Preliminary psychometric testing of the MI questionnaire suggests modest internal reliability. Therefore, results should be interpreted cautiously. Qualitative data responses reflected positivity toward MI, inconsistent exposure and training in MI, and student viewpoints that may be inconsistent with the spirit of MI. These insights highlight the potential relevance of MI and PCC in students’ approach to patient communication. Continued attention to how MI is introduced, taught, and longitudinally supported within DCPs may contribute to more understanding of MI in chiropractic education.
DECLARATIONS
Acknowledgments
The authors would like to acknowledge Katherine Pohlman, DC, MS, PhD and Dustin Derby, MSEd, MS, EdD for their assistance with survey dissemination at their respective institutions.
Funding
No funding was received for this study.
Competing Interests
The authors declare no competing interest.
Data Availability
Data are available for editorial review.
Artificial Intelligence
Artificial intelligence was not used in the preparation of this study.
Contributorship
Concept development: AB, DT, JG. Design: AB, DT, JG. Supervision: JG, DT. Data collection/processing: KH, SL, ZM, MK, KB. Analysis/interpretation: AB, DT, JG, KH, SL, ZM, MK, KB. Literature search: AB, DT, SL, ZM, MK, KM, KB. Writing: AB, DT, SL, KH. Critical review: JG, DT, KH, SL, ZM, MK, KB.
REFERENCES
- 1.Oliveira CB, Maher CG, Pinto RZ, et al. Clinical practice guidelines for the management of non-specific low back pain in primary care: an updated overview. Eur Spine J. 2018;27(11):2791–2803. 10.1007/s00586-018-5673-2 [DOI] [PubMed] [Google Scholar]
- 2.Dowell D, Ragan KR, Jones CM, Baldwin GT, Chou R. CDC clinical practice guideline for prescribing opioids for pain — United States, 2022. MMWR Recomm Rep. 2022;71(3):1–95. 10.15585/mmwr.rr7103a1 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Ramond-Roquin A, Bouton C, Bègue C, Petit A, Roquelaure Y, Huez JF. Psychosocial risk factors, interventions, and comorbidity in patients with non-specific low back pain in primary care: need for comprehensive and patient-centered care. Front Med. 2015;2:73. 10.3389/fmed.2015.00073 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Walker BF. The prevalence of low back pain: a systematic review of the literature from 1966 to 1998. J Spinal Disord. 2000;13(3):205–217. 10.1097/00002517-200006000-00003 [DOI] [PubMed] [Google Scholar]
- 5.Hartvigsen J, Hancock MJ, Kongsted A, et al. What low back pain is and why we need to pay attention. Lancet Lond Engl. 2018;391(10137):2356–2367. 10.1016/S0140-6736(18)30480-X [DOI] [PubMed] [Google Scholar]
- 6.GBD 2021 Low Back Pain Collaborators . Global, regional, and national burden of low back pain, 1990–2020, its attributable risk factors, and projections to 2050: a systematic analysis of the Global Burden of Disease Study 2021. Lancet Rheumatol. 2023;5(6):e316–e329. 10.1016/S2665-9913(23)00098-X [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Kasimis K, Apostolou T, Kallistratos I, Lytras D, Iakovidis P. Effects of manual therapy plus pain neuroscience education with integrated motivational interviewing in individuals with chronic non-specific low back pain: a randomized clinical trial study. Medicina (Mex). 2024;60(4):556. 10.3390/medicina60040556 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Alperstein D, Sharpe L. The efficacy of motivational interviewing in adults with chronic pain: a meta-analysis and systematic review. J Pain. 2016;17(4):393–403. 10.1016/j.jpain.2015.10.021 [DOI] [PubMed] [Google Scholar]
- 9.Motivational Interviewing Network of Trainers (MINT) . Understanding motivational interviewing. Accessed March 15, 2025. https://motivationalinterviewing.org/understanding-motivational-interviewing
- 10.Lord SP, Sheng E, Imel ZE, Baer J, Atkins DC. More than reflections: empathy in motivational interviewing includes language style synchrony between therapist and client. Behav Ther. 2015;46(3):296–303. 10.1016/j.beth.2014.11.002 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Bahafzallah L, Hayden KA, Raffin Bouchal S, Singh P, King-Shier KM. Motivational interviewing in ethnic populations. J Immigr Minor Health. 2020;22(4):816–851. 10.1007/s10903-019-00940-3 [DOI] [PubMed] [Google Scholar]
- 12.Uzun S, Gürhan N. The effect of motivational interviewing on quality of life and self-efficacy behaviors of individuals with chronic illness: a meta-analysis study. Public Health Nurs Boston Mass. 2024;41(5):901–922. 10.1111/phn.13339 [DOI] [PubMed] [Google Scholar]
- 13.Taheri F, Nasiri A, Namdari S, Salmani F. Effect of motivational interviewing on treatment adherence and self-efficacy of adolescents with asthma: a randomized controlled trial. Nurs Open. 2023;10(7):4373–4383. 10.1002/nop2.1679 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Lundahl B, Moleni T, Burke BL, et al. Motivational interviewing in medical care settings: a systematic review and meta-analysis of randomized controlled trials. Patient Educ Couns. 2013;93(2):157–168. 10.1016/j.pec.2013.07.012 [DOI] [PubMed] [Google Scholar]
- 15.Bischof G, Bischof A, Rumpf HJ. Motivational interviewing: an evidence-based approach for use in medical practice. Dtsch Ärztebl Int. 2021;118(7):109–115. 10.3238/arztebl.m2021.0014 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Zhu S, Sinha D, Kirk M, et al. Effectiveness of behavioural interventions with motivational interviewing on physical activity outcomes in adults: systematic review and meta-analysis. BMJ. 2024;386:e078713. 10.1136/bmj-2023-078713 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Chilton R, Pires-Yfantouda R, Wylie M. A systematic review of motivational interviewing within musculoskeletal health. Psychol Health Med. 2012;17(4):392–407. 10.1080/13548506.2011.635661 [DOI] [PubMed] [Google Scholar]
- 18.Weeks WB, Goertz CM, Meeker WC, Marchiori DM. Public perceptions of doctors of chiropractic: results of a national survey and examination of variation according to respondents’ likelihood to use chiropractic, experience with chiropractic, and chiropractic supply in local health care markets. J Manipulative Physiol Ther. 2015;38(8):533–544. 10.1016/j.jmpt.2015.08.001 [DOI] [PubMed] [Google Scholar]
- 19.Gliedt JA, Schneider MJ, Evans MW, King J, Eubanks JE. The biopsychosocial model and chiropractic: a commentary with recommendations for the chiropractic profession. Chiropr Man Ther. 2017;25(1):16. 10.1186/s12998-017-0147-x [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Kane RL, Olsen D, Leymaster C, Woolley FR, Fisher FD. Manipulating the patient a comparison of the effectiveness of physician and chiropractor care. Lancet. 1974;303(7870):1333–1336. https://doi.org/10.1016/S0140-6736(74)90695-3 [DOI] [PubMed] [Google Scholar]
- 21.Creswell JW, Creswell JD. Research Design: Qualitative, Quantitative, and Mixed Methods Approaches. SAGE Publications; 2018. [Google Scholar]
- 22.von Elm E, Altman DG, Egger M, et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. J Clin Epidemiol. 2008;61(4):344–349. 10.1016/j.jclinepi.2007.11.008 [DOI] [PubMed] [Google Scholar]
- 23.Qualtrics XM - Experience Management Software. Qualtrics. Accessed March 18, 2025. https://www.qualtrics.com/ [Google Scholar]
- 24.Aronson BD, Chen AMH, Blakely ML, Kiersma ME, Wicker E. Evaluation and revision of the Kiersma-Chen Empathy Scale. Am J Pharm Educ. 2022;86(5):8685. 10.5688/ajpe8685 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Blakely ML, Aronson BD, Chen AMH, Kiersma ME, Wicker E, Draime JA. Establishing validity evidence for Parallel Patient-Provider Empathy Scales to Drive self-reflection. Am J Pharm Educ. 2022;86(8):ajpe8801. 10.5688/ajpe8801 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.Foronda C, Porter A, Phitwong A. Psychometric testing of an instrument to measure cultural humility. J Transcult Nurs. 2021;32(4):399–404. 10.1177/1043659620950420 [DOI] [PubMed] [Google Scholar]
- 27.Moyers TB, Rowell LN, Manuel JK, Ernst D, Houck JM. The Motivational Interviewing Treatment Integrity Code (MITI 4): rationale, preliminary reliability and validity. J Subst Abuse Treat. 2016;65:36–42. 10.1016/j.jsat.2016.01.001 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28.Willits D, Albright D, Broidy L, Lyons C. Evaluating motivational interviewing training. Published online July 2009. Accessed July 20, 2024. https://isr.unm.edu/reports/2009/evaluating-motivational-interviewing-training.pdf
- 29.Ekong G, Kavookjian J, Hutchison A. Predisposition for empathy, intercultural sensitivity, and intentions for using motivational interviewing in first year pharmacy students. Am J Pharm Educ. 2017;81(8):5989. 10.5688/ajpe5989 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30.Bernhard G, Knibbe RA, von Wolff A, Dingoyan D, Schulz H, Mösko M. Development and psychometric evaluation of an instrument to assess Cross-Cultural Competence of Healthcare Professionals (CCCHP). PLoS One. 2015;10(12):e0144049. 10.1371/journal.pone.0144049 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 31.Hojat M, Mangione S, Nasca TJ, et al. An empirical study of decline in empathy in medical school. Med Educ. 2004;38(9):934–941. 10.1111/j.1365-2929.2004.01911.x [DOI] [PubMed] [Google Scholar]
- 32.Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77–101. 10.1191/1478088706qp063oa [DOI] [Google Scholar]
- 33.Martino S, Haeseler F, Belitsky R, Pantalon M, Fortin AH., IV Teaching brief motivational interviewing to year three medical students. Med Educ. 2007;41(2):160–167. 10.1111/j.1365-2929.2006.02673.x [DOI] [PubMed] [Google Scholar]
- 34.Daeppen JB, Fortini C, Bertholet N, et al. Training medical students to conduct motivational interviewing: a randomized controlled trial. Patient Educ Couns. 2012;87(3):313–318. 10.1016/j.pec.2011.12.005 [DOI] [PubMed] [Google Scholar]
- 35.Fortune J, Breckon J, Norris M, Eva G, Frater T. Motivational interviewing training for physiotherapy and occupational therapy students: effect on confidence, knowledge and skills. Patient Educ Couns. 2019;102(4):694–700. 10.1016/j.pec.2018.11.014 [DOI] [PubMed] [Google Scholar]
- 36.Westra HA, Aviram A. Core skills in motivational interviewing. Psychotherapy. 2013;50(3):273–278. 10.1037/a0032409 [DOI] [PubMed] [Google Scholar]
- 37.Resnicow K, McMaster F. Motivational interviewing: moving from why to how with autonomy support. Int J Behav Nutr Phys Act. 2012;9:19. 10.1186/1479-5868-9-19 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 38.Miller WR, Rose GS. Toward a theory of motivational interviewing. Am Psychol. 2009;64(6):527–537. 10.1037/a0016830 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 39.Field C, Oviedo Ramirez S, Juarez P, Castro Y. Process for developing a culturally informed brief motivational intervention. Addict Behav. 2019;95:129–137. 10.1016/j.addbeh.2019.03.002 [DOI] [PubMed] [Google Scholar]
Associated Data
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Data Availability Statement
Data are available for editorial review.