Motivational Advising Workshop: Utilizing Motivational Interviewing Theory to Facilitate and Engage Intrinsic Motivation to Change Learners' Behavior

Abstract

Introduction

Motivational interviewing (MI) is a counseling method that utilizes a patient's own motivation to effect personal change. MI has been applied routinely and successfully to managing medical conditions (e.g., substance abuse). Employing MI techniques to engage medical learners (termed motivational advising [MA]) may help them overcome professional and/or personal challenges limiting their career development.

Methods

Medical educators from four academic medical centers developed a module focused on teaching fellow educators MI theory and techniques for MA using didactic and interactive components. Participants participated in facilitated role-plays to practice MA delivery techniques and observed videos of a traditional advisor-advisee interaction as well as an MA-focused engagement. A postworkshop survey was used to evaluate the workshop.

Results

In a survey of 48 educators attending the workshop at two medical conferences, over 80% of respondents demonstrated an interest in learning more about MA. Additionally, over 60% indicated that they would seek opportunities to practice and/or implement MA with their advisees. Knowledge of the technical components of MA also increased significantly in pre- and posttest analysis.

Discussion

This module introducing the concept of MA was well received by medical educators and was viewed as a valuable tool in advising medical learners. The provided components enable replication of this workshop in other settings with or without an expert in MI techniques. Although the workshop has been conducted with physicians involved in medical education, it would be applicable to other health professionals who advise trainees such as nursing, dentistry, pharmacy, or veterinary medicine.

Educational Objectives

By the end of this activity, learners will be able to:

• 1.Define motivational interviewing and motivational advising.
• 2.Differentiate sustain talk from resistance.
• 3.Utilize statements to move a conversation with a medical learner forward.
• 4.Practice motivational advising techniques in a case-based role-play.
• 5.Access resources for further practice applying motivational interview techniques.

Introduction

Educators in the health professions who advise learners may be called upon to address problem behaviors such as professionalism lapses (e.g., chronic tardiness, repeated failures to complete documentation). While addressing behavior modification with medical learners can be difficult, changing such behaviors is essential to avoid negatively affecting learning, patient care, and practice.¹ For example, Papadakis, Hodgson, Teherani, and Kohatsu demonstrated that unprofessional behavior in medical school was associated with disciplinary action by state medical boards.² Learners with persistent problem behaviors may benefit from motivational advising (MA)—advising that uses the core principles and skills of motivational interviewing (MI) to help the learner make internally motivated decisions to change behavior.

MI, a counseling approach first described by Miller and Rollnick in the early 1980s, is designed to harness a patient's own motivation and commitment to change.³ MI can be viewed as a more intentionally directive method of patient-centered, goal-oriented counseling where the provider helps influence the patient to make a decision for behavior change rather than telling the patient what to change. Although originally developed to address behaviors related to substance use disorders, MI techniques have been successfully applied to promote behavior change in multiple other health-related domains including glucose control, weight management, and physical activity.³ MI encompasses a set of core principles and skills that can be learned by providers.⁴

Understanding and practicing the techniques of MI can provide advisors in the health professions education with an additional tool, especially for difficult advising situations where behavior change is desired but has not occurred. We chose this topic for a workshop based on our collective experiences counseling learners with behaviors that were resistant to typical advising techniques. We felt a need to provide additional skills to health professions advisors. As competency-based medical education, with its emphasis on observable behaviors, becomes more prominent, MA provides a tool specifically designed to address needed behavior changes.^5,6 MA is a collaborative process that supports learners in developing their own goals, which is an essential skill for health professionals at all levels of training. A single institution piloted the workshop, and participants found it extremely helpful. To our knowledge, the application of MI techniques to advising in the health professions has not been previously described in the literature, and we believe it is a novel approach to a challenging issue. Thus, we developed a formal workshop to teach the concepts and techniques of MA.

We used Kern's six-step model as a framework to guide curricular development.⁷ The problem was initially identified during a faculty development session for academic coaches at a single institution, and a targeted needs assessment was performed via a focus group. Next, goals and objectives were developed in an iterative fashion based on literature review and group consensus. The team chose Kolb's learning cycle—concrete experience, reflective observation, abstract conceptualization, and active experimentation—to guide workshop development, with an emphasis on interactive learning strategies.⁸ The workshop was implemented at two national conferences for medical educators. Participants and presenters were from multiple institutions. A paper questionnaire was developed for participants to evaluate the workshop experience.

This resource has been implemented as a stand-alone workshop for advisors, mentors, and coaches in the health professions. The core concepts of MI techniques are covered along with the application of these concepts to advising practice. Ample time is then spent practicing the techniques in role-play scenarios. The workshop is designed so that no prior experience with MI is required.

Methods

The workshop was developed by a team of experts in an iterative fashion. The team consisted of eight individuals with expertise in medical student advising (medical school deans/clerkship directors), resident advising (program director), MI techniques (psychiatrist), and a medical student (who viewed materials from the medical learner perspective). The workshop was designed to introduce the techniques of MI and their application to advising learners. The workshop can be implemented with faculty who advise medical students, residents, and/or fellows. It can also be expanded to any faculty who advise learners in the health professions. The preferred facilitator(s) would have experience advising learners in the health professions and/or experience in the techniques of MI. The workshop is laid out in the facilitator guide (Appendix A).

The workshop was designed to engage participants with active learning strategies and transition them through Kolb's learning cycle—concrete experience, reflective observation, abstract conceptualization, and active experimentation.⁸ The workshop began with a PowerPoint presentation (Appendix B) that introduced the facilitators and their expertise. This was followed by a video of advising as usual (Appendix C) to provide context for participants and demonstrate a concrete experience of advising a learner who needs to modify a behavior. Large-group discussion followed and provided space for reflective observations on the video as well as reflection on participants' cases of learners with reluctance to change. Next, a didactic presentation on the techniques of MA was conducted (Appendix D). This emphasized the core concepts of MA and provided techniques. Participants then watched a video of MA in action (Appendix E) to demonstrate the core concepts and facilitate abstract conceptualization. This was followed by a role-play exercise in small groups (Appendix F). Each group worked through common challenging advising scenarios to encourage active experimentation with MA techniques. Each case was debriefed in the small groups and the large group to promote feedback and reflection. The workshop concluded with a summary of the key points from the cases and encouraged participants to continue practicing and to implement the techniques in their current advising strategies (Appendix G). The evaluation form (Appendix H) was given out at the conclusion of the workshop. To ensure success of the workshop, below is a listing and description of the resources provided.

Appendix A: Facilitator Guide

The facilitator guide provides step-by-step instructions on how to deliver the workshop, including talking points for each slide, instructions for the role-play exercise, and instructions on how to insert the videos into the PowerPoint presentation.

Appendix B: PowerPoint Presentation

The nine-slide PowerPoint presentation guides the workshop. Three videos are included as separate appendices and need to be inserted into the presentation prior to delivery. Facilitators with previous experience teaching MI can choose not to insert Video 2 and use their own resources to teach MI techniques if preferred.

Appendix C: Video 1 (Advising as Usual)

The video was created by the workshop authors and depicts a clerkship director advising a clerkship student in typical fashion. The roles of clerkship director and student were played by two of the workshop authors (Amy Fleming and Thomas E. Klink). This video can be inserted into the PowerPoint presentation on slide 3.

Appendix D: Video 2 (Techniques of Motivational Advising)

Given that those wishing to use our workshop may have limited (or no) experience in MI techniques, this video was created by a workshop author (Margaret Benningfield) with expertise in teaching and applying MI. When the workshop was conducted, the author was present to deliver this component of the workshop; however, the video can be inserted into the PowerPoint presentation on slide 5: Introduction to the Techniques of Motivational Advising.

Appendix E: Video 3 (Motivational Advising in Action)

The video was created by the workshop authors and depicts a clerkship director advising a clerkship student using MA. The roles of clerkship director and student were played by two of the workshop authors (Margaret Benningfield and Thomas E. Klink). This video can be inserted into the PowerPoint presentation on slide 6: Motivational Advising in Action.

Appendix F: Cases for Role-Play

The cases are distributed to participants after the role-play instructions (slide 7) are given and include three cases of common advising situations that guide the role-play.

Appendix G: Handout

The handout is distributed to participants when the facilitator is summarizing the workshop and includes key techniques of MA and additional resources for further study.

Appendix H: Evaluation Form

The evaluation form was given to participants at the conclusion of the workshop. Since the application of MI techniques to advising situations was novel to many participants, they retrospectively rated their preworkshop knowledge of three core concepts on a scale from 1 (no knowledge) to 5 (extensive knowledge) as well as their postworkshop knowledge. Motivation to continue learning about MA, seeking opportunities to practice techniques, and likelihood of using the techniques in actual practice were rated using a 4-point Likert scale. The form took approximately 5 minutes to complete.

Review of materials (facilitator guide, PowerPoint presentation, cases, videos, handout, and evaluation form) took approximately 2 hours to complete. To allow for adequate feedback to workshop participants during the role-play exercise, there should be one facilitator for approximately every 12 participants. Facilitators should decide in advance who will be conducting each component of the workshop. For participants, there is no preparation needed prior to workshop attendance.

Required materials for a successful workshop include a laptop, projector, and screen with audio capabilities to display the PowerPoint presentation and the videos; a flip chart or whiteboard and markers to facilitate the large-group discussions and role-play debrief; pens for participants to take notes with during the role-play; and printed copies of the cases for role-play, handout, and evaluation form for all participants.

The optimal length of the workshop is 120 minutes, but it can be tailored to local need. A time line is below:

• •Introduction of facilitators: 5 minutes.
• •Video of normal advising in action: 5 minutes.
• •Discussion of learners with reluctance to change (situation, context, learning environment) and reasons learners have not been successful: 10 minutes.
• •Introduction to MA techniques: 20 minutes.
• •Video of MA in action: 5 minutes.
• •Debrief of MA in action video: 5 minutes.
• •Break: 5 minutes.
• •Introduction of role-play exercise: 5 minutes.
• •Facilitated role-play in small groups with large-group debrief: 50 minutes.
• •Summary and conclusions: 10 minutes.

Results

The workshop was facilitated by the authors and implemented first at the 2017 Annual Meeting of the Council on Medical Student Education in Pediatrics as a 120-minute workshop. Thirty learners participated in the initial session. The workshop was repeated as a 90-minute session at the 2017 Regional Conference of the Southern Group on Educational Affairs; 18 learners participated in the workshop.

At the conclusion of the workshop, learners felt that the educational objectives had been met. All learners felt that they could define MI and MA, use statements to move a conversation forward, apply MI skills to student advising, and access resources for further practice applying MI techniques. Nearly all (95.8%) learners felt that they could differentiate sustain talk from resistance. The average rating of agreement with the statement “As a result of this workshop, I became more comfortable using MI/MA” was 4.2 and 4.6 for each offering, respectively (based on a 5-point Likert scale). Of all the learners who attended the workshop, 80.4% were very likely to learn more about MA, 73.9% were very likely to seek opportunities to practice MA, and 62.2% were very likely to implement MA at their institution. There was a statistically significant increase in participants' self-reported knowledge, as detailed in the Table.

Table. Retrospective Pretest and Posttest Self-Rating of Knowledge.

Knowledge Domain	M		p
	Pretest	Posttest
Knowledge of fundamental techniques of motivational interviewing	2.2	3.8	<.001
Knowledge of change talk	1.9	3.7	<.001
Knowledge of sustain talk	1.4	3.4	<.001

Two authors performed thematic analysis of the qualitative comments from both workshops. The role-play exercise with facilitator feedback and the video examples of MA were identified as the most valuable aspects of the workshop. Example comments included “Role plays tough but super worthwhile” and “Seeing examples of using MA (to see it in practice).” Thematic analysis of comments on the question “What was the least valuable aspect of this workshop?” indicated that participants wanted more time to practice and role-play. A representative comment was “Wish there was more time for the workshop.”

Discussion

The workshop was designed to introduce and teach the core techniques of MA, which may be particularly useful when advising learners with reluctance to change. The workshop achieved its goal as participants demonstrated increased knowledge of MI techniques as well as a desire to learn more about MA and incorporate MI techniques into their advising practices. Participants felt the objectives of the workshop had been achieved, and their evaluations identified the most and least valuable aspects of the workshop. Although we conducted this workshop at national meetings primarily targeting physicians, it could be performed with any health professional in an advising role. Additionally, the workshop does not require prior knowledge of MI, making it accessible to a wide audience.

A critical factor for success was the interactive nature of the workshop with opportunities for participants to practice MA and receive real-time feedback. In conducting the workshop, it is essential to have enough facilitators for the number of participants. Although an MI expert is not necessary to conduct the workshop, attendance of an expert will likely be beneficial as the expert can help provide more in-depth, real-time feedback, an aspect highly valued by participants. The greatest challenge in conducting the workshop was providing enough time for participants to practice the techniques.

Limitations of the workshop include that it was a singular, brief session and that evaluation was limited to self-perceptions. Although the workshop motivated participants to seek additional opportunities to explore and practice MA techniques, it is unknown what the participants' actual behavior was in the postworkshop period. It would be helpful to have follow-up assessments to determine if and how participants used the information learned in the workshop in their advising practices. Additionally, as with developing any new skill, participants likely need repeated practice sessions to foster skill development. To meet these challenges, the workshop could be expanded to include additional practice cases, or a series of workshops could be developed. Lowering the facilitator-to-participant ratio could also promote more practice per participant with increased feedback.

We believe that this workshop can provide health professions advisors with a useful tool for difficult advising situations, especially if learners are reluctant to change. To the best of our knowledge, this is the first workshop of its kind. We hope that MA can motivate change in the learner and allow continued professional development and growth.

Appendices

A. Facilitator Guide.docx

B. PowerPoint Presentation.pptx

C. Video 1 Advising as Usual.mp4

D. Video 2 Techniques of Motivational Advising.mp4

E. Video 3 Motivational Advising in Action.mp4

F. Cases for Role-Play.docx

G. Handout.docx

H. Workshop Evaluation.docx

All appendices are peer reviewed as integral parts of the Original Publication.