Applying Motivational Interviewing Strategies to Enhance Organizational Readiness and Facilitate Implementation Efforts

Abstract

Motivational Interviewing (MI) is an empirically supported clinical method to help individuals make behavioral changes to achieve a personal goal. Through a set of specific techniques, MI helps individuals mobilize their own intrinsic values and goals to explore and resolve ambivalence about change. This article examines how MI-informed approaches can be applied to help staff to adopt new evidence-based practices in organizational settings. While the implementation science literature offers strategies for implementing new practices within organizations, leaders of quality improvement initiatives often encounter ambivalence about change among staff. Implementation approaches which require staff to make substantial changes may be facilitated by drawing from MI strategies. These include: building a sense of collaboration from the beginning, eliciting “change talk”, and addressing any ambivalence encountered. MI techniques may be particularly helpful in working with those in a stage of precontemplation (who have yet to see a reason for change) and those who are contemplating change (who see that a problem exists but are ambivalent about change). This article provides examples of how an MI-informed approach can be applied to help facilitate change in staff within organizations that are implementing quality improvement initiatives. These techniques are illustrated using a representative scenario.

First described by W.R. Miller in 1983, further developed by Miller and Rollnick¹ and updated in 2013,² motivational interviewing (MI) is an individual counseling approach to resolve ambivalence to bring about behavioral change. It was initially formulated as an approach for helping motivate people to reduce substance use and has since generated multiple adaptations designed to support behavior change for a wide range of issues from reducing HIV-risk behaviors³ to obesity and diabetes management.⁴ While these empirically-supported techniques have been used to facilitate change among individuals to achieve a personal goal, here we discuss how these techniques also can be applied to facilitating change among staff within organizations trying to adopt new evidence-based practices.

Within this paper we describe specific tools and techniques drawn from MI as a potential resource for those charged with implementing organizational change. Our goal is to provide a practical guide for what implementation of MI strategies might look like from the viewpoint of someone asked to lead such efforts.

Motivational Interviewing

MI comprises a specific set of strategies and techniques to help motivate ambivalent individuals towards behavior change.² MI presumes personal autonomy, that people will make their own choices, hence the clinician’s task can be identifying and enhancing a person’s motivation to change. This is achieved by selectively reinforcing self-motivational statements (or “change talk”) by getting individuals to talk about their own desire, ability, reason, need, and commitment to change. “Sustain talk” (i.e., comments that suggest the individual wants to keep things the way they are) is seen as a normal part of ambivalence that can be increased or decreased as a product of an interpersonal interaction.¹

When contemplating how to motivate behavior change, it can be helpful to identify a person’s stage of readiness for change using Prochaska and DiClemente’s transtheoretical model of change in which an individual’s readiness for change can be conceptualized along the following five stages: Precontemplation, Contemplation, Preparation, Action, and Maintenance.⁵ Even though MI and the transtheoretical model of change arose independently, MI can be helpful in stimulating movement from one stage to the next, using stage-appropriate strategies.⁶

The basic premise, or spirit, of motivational interviewing described by Miller and Rollnick is that harnessing intrinsic motivations to change can be more effective than external pressures.¹ A core tenant uniting these techniques is the belief that an empathic counseling style is more likely to facilitate change than a confrontational one. An additional tenant is the idea that attempting to persuade or argue for change sets up a dynamic where the individual being asked to change argues against it, a natural and predictable response to ambivalence, thereby reinforcing, rather than reducing, reluctance to change. Within MI, an emphasis on individual autonomy, and freedom of choice is key.

Adopting an MI Approach to Facilitate Organizational Change

Those leading quality improvement (QI) initiatives are often faced with staff who may express reluctance, reservations, and concerns about change, or exhibit ambivalence about change by appearing disengaged or even hostile. Clinical administrators and others charged with facilitating the implementation of new practices often are in the position of having to implement new initiatives in response to “top down” mandates. While quality improvement theory offers a strategy for tackling the change process through iterative small steps (setting goals, making a change, reviewing outcomes, modifying the approach, and trying again), it is silent on the following common concerns: What are effective ways to engage the group as collaborators in the implementation process? What are effective ways to manage the various types of ambivalence to change so often encountered in the change process?

In implementation science, there is an emerging consensus around the importance of working with staff collaboratively to implement a change. A recent compilation of implementation strategies includes four that are directly related to this collaboration: assessing for readiness and identifying barriers and facilitators to change, building a coalition, conducting local consensus discussions, and facilitation (defined as a process of interactive problem solving and support in a context of a recognized need for improvement and a supportive interpersonal relationship).⁷ MI may be one route to implementing these strategies.

Several authors have suggested that MI approaches may be particularly useful in facilitating organizational change.^8-11 Some of the strategies described for creating motivation for organizational change include highlighting discrepancy between current and desired outcomes, fostering and encouraging dissatisfaction with the status quo, and supporting not only individuals’ wish to change, but their confidence that they can change.¹² Many of these previously described strategies are also found in MI. It is important to note that, in situations where change is mandated in an organization, individual autonomy and personal choice may be limited. However, studies of people who have been mandated to treatment suggest that MI can still be employed effectively to engage people, increase motivation to change, and affect positive outcomes.^13-14

A few recent implementation studies have provided some evidence to support the use of MI-informed approaches in enhancing organizational readiness for change and improving uptake of evidence-based practices. Exposure to three MI sessions significantly increased readiness to change in a group of employees in a company undergoing change as compared to a control group within the same company.¹¹ In another implementation study looking at the adoption of MI as an evidence based practice, MI-based implementation coaching was more effective than passive dissemination strategies.¹⁰ Our own experience, described in the examples below, also suggests that MI strategies offer an effective framework for enhancing organizational readiness for change and addressing the inevitable ambivalence encountered.

Application to Practice: A Case Example

Consider the following scenario: A clinical administrator sees that treatment drop-out rates for people with substance use disorders are unusually high. She reviews the evidence base and decides to implement a new practice to improve rates of engagement in treatment for people who misuse substances. The administrator implements a multidisciplinary training program. During the training, one clinician is particularly vocal about her frustration with people who misuse drugs and alcohol. Other clinicians appear disengaged, using their mobile devices. One clinician comments that the “quality-improvement initiatives du jour” rarely seem to make a difference. Another clinician expresses annoyance about the extra work that this initiative will require, noting that the team is already overwhelmed by staffing cuts, learning new billing codes, and adapting to a new electronic medical record. One clinician who has worked at the clinic for years says, “To me things are going fine. I am not sure why we need to make any changes.” The clinical administrator had hoped to get her team members interested, motivated, and engaged in implementing a new practice; however, after hearing these reactions, she has begun to question her ability to implement the new clinical practice.

Such situations will be familiar to many readers charged with implementing change. Conversations that include sustain talk can undermine implementing new evidence-based practices. QI initiatives frequently face ambivalent staff who are actively or passively committed to alternatives, including the status quo. There is a relative gap in the QI literature about ways to increase these participants’ motivation to adopt the new practice. Many QI strategies are targeted towards learners already in the Action phase of the change process. Indeed, strategies often suggest starting with motivated learners and capitalizing on early adopters.¹² Such an approach begs the question of how best to address those who remain ambivalent or who are committed to not changing, which is particularly important when the ambivalent staff are natural opinion leaders among peers.

Beyond broad general principles for creating motivation described above, what are specific MI techniques and how might they apply to implementing change? In our view, the MI strategies most applicable to facilitating adoption of institutional QI initiatives fall into three broad categories: (1) building a sense of collaboration from the beginning, the “engagement process;” (2) resolving ambivalence by eliciting change talk, the “evoking process;” and (3) lowering sustain talk and discord.

Build a Sense of Collaboration from the Beginning

Literature in the field of implementation science has emphasized the importance of understanding and preparing for organizational change in the process of implementing new evidence-based practices.¹⁵ Establishing organizational readiness is complex and multifactorial, requiring financial, material, and human resources.¹² Buy-in from stakeholders is critical to getting the organizational change process going; staff input and shared decision making during the implementation process enhances the likelihood of achieving organizational change.

In implementing an innovation or evidence-based practice, buy-in from all levels within an agency or program is key to the process. By buy-in, we mean that individuals within the agency or program believe it is important to implement the innovation and that they have the resources and know how to be able to successfully complete the implementation process. That is, using motivational interviewing language, they have to both want to and feel able to incorporate the innovation.

Engaging staff in the implementation process facilitates buy-in. The process of collaboration and partnership is the first step, and the first meeting sets the foundation for the rest of the process. Motivational interviewing theory emphasizes the importance of an opening structure for this initial meeting. For external consultants charged with leading change, this structure should include telling staff who you are, why you are present, by whom you were invited, details of the proposed initiative, and why the proposed initiative is being undertaken. Additionally, an agenda, timeframe, and roles for the proposed initiative should be included in this initial meeting. It is critical for leaders to consider the time needed to achieve buy-in in establishing initiative timeframes; it should always be assumed that time to adequately address participant concerns and achieve full buy-in is needed before the remainder of an initiative timeline can proceed. It should be stated explicitly that the proposed initiative cannot work without these staff, and they are an important, if not the important ingredient in this initiative.

Next, MI theory indicates that it is important to learn what staff already know about the proposed initiative and what they think and feel about it by asking them in a way that facilitates open and honest responding. Of course, eliciting worries and concerns may increase ambivalence around the proposed change. However, it’s important to validate any concerns and worries using reflective listening or paraphrasing back what is said in a way that conveys understanding without an effort to try to steer staff towards accepting the initiative. After the initiative is described in detail, ask staff again about their reactions to the proposal, listening and reflecting any additional feedback. In MI theory, this is known as the “elicit-provide-elicit” process. Throughout this process, affirm each person’s strengths, experience, and expertise.

As part of this process, it’s valuable to ask staff about the population with whom they are working, and ways in which they perceive the proposed initiative as potentially benefitting this population and helping their work (thereby eliciting change talk). As described above, listen for signs that participants have the desire, ability, reason, need, commitment, and activation to change, as well as any evidence that they may already be taking steps to change (the DARN-CAT) as shown in Table 1.

Table 1.

Examples of the DARN-CAT

Desire	I am interested in learning how to use this new practice.
Ability	I know I can incorporate this new practice in my work.
Reason	If I use this new practice it will help improve outcomes for the people we serve.
Need	I really need to make this change to better help the people we serve.
Commitment	I will take the extra time needed to learn this new practice.
Activation	I am ready to make the changes needed to implement this new practice.
Taking Steps	I tried using two of the skills of the new practice.

In working to build a sense of collaboration, motivational interviewing would suggest that certain strategies or language be avoided. In proposing a new initiative, it is important to not go in as the expert telling staff what they need to do. The introduction of new initiatives and training programs often come across as saying, “You’re doing it wrong…let me tell you how to do it right.” This sets up an unfavorable dynamic from the start, particularly among team members who bring years of experience to the table. Instead, strive for an introduction that builds on current strengths and trajectories. Staff should not be made to feel badly about what they are currently doing; to do so only invites defensiveness and “sustain talk”. When proposing a new initiative, it is critical to not rush or get ahead of staff in their readiness to adopt changes. Instead, the techniques outlined below offer routes to building engagement and a sense of collaboration early in the initiative.

Resolving Ambivalence by Eliciting Change Talk

MI provides strategies for eliciting change talk from the target audience, to be applied in concert with strategies aimed at lowering sustain talk, discord, and ambivalence. Eliciting change talk (highlighted in Table 2) speaks to the tenant of self-efficacy that undergirds much of MI strategies. That is, staff are encouraged to create their own language of change rather than being provided with this language by the individual presenting the new intervention. It also provides opportunities for the individual presenting a new initiative to highlight discrepancies between staff’s sustain talk and desire to change, using staff’s own language.

Table 2.

Motivational Interviewing Strategies and Examples for “Eliciting Change Talk”

STRATEGY	DESCRIPTION	EXAMPLE
Asking Evocative Questions	Simply ask open questions, the answers to which include change talk.	“How do you think this new practice can help you in your work?” “How might implementing this new practice improve outcomes for your clients?”
The Importance Ruler	Have each person rate on a scale from zero to ten how important it is for them to incorporate the new intervention in their work, where zero is not at all important, and ten is extremely important. Anything above a zero means that the person acknowledges something positive about the initiative.	“How important is it to you that we implement this new practice?” Why did you select that number and not a lower number? e.g. “Why did you select a 3 and not a 1?” Whatever they answer are their reasons for change.
Looking Forward	Ask how their work might be different if they did decide to change to the new intervention, or ask what may happen if they decide not to change	“If you do decide to make a change in your work to include the new practice, what do you hope might be different in the future?” “Suppose you don’t make any changes, but just continue as you have been. What problems do you foresee for a year from now?”
Looking Back	Ask about previous time when they made a helpful change at work. How did they do that? Ask for similarities with present situation.	“When was a time when there was a helpful change to your job? What was that like? What did you do to make that change successful? How might those adjustments be helpful now?”
Query Extremes	Ask the team member to describe the worst thing they can imagine if don’t change or to imagine the best things if they do change.	“What are the worst things that might happen if you don’t implement the new intervention?” “What are the best things that might happen if you implement the new intervention?”
Exploring Goals and Values	Ask the person to explore their goals and values that brought them into the work they are doing. Then look for examples where current practices might conflict with their goals and values. Help the person recognize the discrepancy between his/her personal goals/values and current practices.	“I know helping your clients is very important to you. How does this new practice fit in with what you value?” “You really would like to see all your clients be successful. What in your current practices might get in the way?”

Lowering Sustain Talk and Discord

In concert with building a sense of collaboration from the beginning and resolving ambivalence by eliciting change talk, MI theory conveys strategies for lowering sustain talk and discord. “Sustain talk” refers to statements that indicate the staff’s reluctance to take on a new behavior (in this case, the new evidence-based practice) in favor of maintaining the status quo (e.g., “To me things are going fine. I am not sure why we need to make any changes.”) whereas “discord” indicates a breakdown in collaboration and alliance between staff and those suggesting change. In the example above, several staff make comments consistent with sustain-talk. Arguing, interrupting, and negating all represent examples of discord. Rather than viewing sustain talk and discord as staff being “resistant” to change, think of sustain talk and discord as signals that staff view the situation differently than those who are asking that the new practice be implemented.

Sustain talk and discord may indicate that participants are not ready for change. They might be in the earliest, precontemplative phase of the change process. In the vignette introducing this article, we included several examples of group participants exhibiting responses typical of individuals in the precontemplative phase. These responses can include expressing a sense of being overwhelmed with the problem at hand, pushing back against what is perceived as coercive or forcible change, feeling inertia due to a lack of knowledge regarding new initiatives, and offering intellectualized counterpoints as a form of sustain talk. Sustain talk and discord can also occur throughout the change process, signaling that the person championing the change is out of step with staff. For example, a staff member in contemplation who is still weighing the pros and cons of the new practice may respond to a premature push toward action with sustain talk or discord.

Adjusting to sustain talk and discord is similar to avoiding argument in that it offers another chance to express empathy by remaining nonjudgmental and respectful, encouraging people to talk and to stay involved, and diverting the energy toward finding shared experiences and goals. MI-informed ways of responding to sustain talk and discord include offering validation to people, listening empathically and reflectively, and affirming the autonomy of personal choice, where possible, as described in Table 3.

Table 3. Motivational Interviewing Strategies and Examples of Responding to Sustain Talk and Discord.

A variety of potential MI strategies are described based on the scenario presented at the beginning of this article.

STRATEGY	DESCRIPTION	EXAMPLE
Simple Reflection	Responding to sustain talk by repeating the person’s statement in neutral form	Stakeholder Comment: “I am not really interested in working with people with drug problems.” Response: “Working with people with drug problems isn’t something you want to do.”
Amplified reflection	Reflecting the statement in a slightly exaggerated form – to state in a more extreme way, without sarcasm, to help encourage the person to consider the other perspective	Stakeholder Comment: “I am not really interested in working with people with drug problems.” Response: “Working with people with drug problems is something you won’t do.”
Double-sided reflection	Acknowledging what the individual has said, while also noting contrary things that he/she has said in the past (encouraging ambivalence rather than only seeing one side)	Stakeholder comment: “These new initiatives rarely seem to make a difference in treatment and outcomes.” Response: “You would like to make a difference and are concerned that this is just another initiative that will fail.”
Shifting focus	Defusing sustain talk by helping the participant shift focus away from obstacles and barriers	Stakeholder comment: “These new initiatives rarely seem to make a difference in treatment and outcomes.” Response: “What changes would you like to make?”
Agreement with a twist	To agree with the person, but with a slight twist or change of direction that propels the discussion forward	Stakeholder comment: “I am not sure we can do this. We are already overwhelmed.” Response: “You feel that there might not be enough time to learn this new practice even though it might work well.”
Reframing	Offering a new and positive interpretation of negative information	Stakeholder comment: “I am not sure we can do this. We are already overwhelmed.” Response: “I really appreciate how hard you work and your willingness to consider new ways to help.
Emphasizing Personal Choice and Control	Reassuring participants about self-determination	Stakeholder comment: “To me things are going fine. I am not sure why we need to make any changes.” Response: “I’m interested in hearing more about how you want to proceed.”

While hearing ambivalence, sustain talk, or discord from participants can be disheartening or frustrating for those leading QI initiatives, it is good to have these barriers identified so that you can respond to them in non-defensive ways. Avoiding defensiveness is important because, if a leader states one-sided reasons for change, then people who aren’t yet motivated to change may be prompted to “defend” the position against change, increasing their motivation to stay the same. Even if a person’s comments seem inappropriate, direct confrontation, particularly in front of other staff, does nothing to engage the person as a collaborator and a team member and risks reinforcing sustain talk.

By building collaboration from the beginning, resolving ambivalence by eliciting change talk, and lowering sustain talk and discord, individuals charged with implementing new initiatives can increase motivation for change. These approaches share the goal of encouraging staff to produce their own language of change and to enhance motivation and behavioral change.

Discussion

Within healthcare, there has been a growing recognition of the importance of “patient centered care” and of building an alliance and engaging the patient as a collaborator. Just as these constructs are important when assisting people in increasing motivation to change, they also are important to the process of engaging staff members in organizational change. This paper presents MI as a readily adaptable strategy for approaching QI, particularly for engaging staff who are not yet in favor of change. Many organizational leaders engaged in QI are unfamiliar with MI and the potential value of these strategies for facilitating change. This article provides an introduction to this framework and provides examples of how specific MI techniques can be applied to QI challenges.

MI began as a way of helping individuals. Indeed, an earlier edition of Miller and Rollnick’s text notes how a group setting may add an extra layer of difficulty to the processes of expressing empathy, enhancing discrepancy between current and desired outcomes, avoiding argument and confusion, and encouraging self-efficacy and change talk.¹⁶ Although the evidence is limited, data currently available is encouraging and suggests multiple ways MI might be adapted to accommodate group settings.¹⁷ Even if one-on-one approaches were the fastest way to help a person change, such approaches may not be scalable for large organizations where sequential one-on-one interventions simply may not be feasible. Leaders facing implementing new practices in large institutions might consider group adaptations to MI that would include the occasional one-on-one meeting with key individuals and limiting the size of groups to ensure that they hear from each person.^{16, 18-19}

The spirit of motivational interviewing is a “bottom up” model of QI that develops collaboration as opposed to requesting change using confrontation and authority. At first blush, this spirit may seem to clash with features of QI in the workplace that differ from clinical treatment, including the presence of inherent levels of authority/hierarchy, the mandated nature of some QI initiatives, and the presence of extrinsic motivators (e.g. fear of termination). Yet, many people seeking a therapist’s help are having change forced upon them (their spouse is divorcing them; they are losing their housing; they’ve been fired from their job), and MI can help the person decide how to address behaviors that precipitated the change. In fact, implementing evidence-based practices in the workplace may be somewhat easier than these examples since they don’t typically have the same emotional impact. It’s important to remember that individuals in an organization maintain some level of autonomy even in the face of directives and extrinsic motivators (it’s the exceptional initiative that has 100% participation), hence incorporating the spirit of MI-informed intervention can help motivate people to choose to participate. For example, leaders might utilize MI to facilitate conversations of how to implement a mandated change rather than whether to do so.

While change may be directed from the top, each individual still has the autonomy to choose whether to comply with directives to change or experience the consequences of not complying, and therein lies the potential for MI to help motivate change for staff that are ambivalent or reluctant to change. Getting buy-in is critical to implementation success, hence increasing staff’s motivation to change is key. A leader’s skill in eliciting change talk that increases motivation for change among staff may improve buy-in and ensure successful implementation; lack of such skills may pave a path of failed quality improvement initiatives and programs.