Backed by over 200 clinical trials and multiple meta-analyses, motivational interviewing (MI) is the gold standard for health coaching. MI can be effective in single or multiple brief encounters, face-to-face or over the phone. MI is also practical for use across the care continuum—from employees in a corporate wellness program to patients with multiple chronic conditions— where it can be most effective. However, since MI is not tied to any one discipline or role, e.g., case manager, it is ideal as a practice platform shared by the interdisciplinary team. And unlike traditional medical or patient education-oriented approaches, MI is patient-centered by design.
MI is particularly effective with patients described as “resistant” or “difficult to engage.” While MI originally emerged from the addictions field, there are clear parallels in health care. Many patients targeted for case management have been lectured and scolded about their smoking, weight or inactivity—as most problem drinkers have been about their drinking. Yet regardless of the patient’s challenge, in MI we meet the patient where they are—not where they should or could be. For this same reason, MI is ideal for patients from various cultures or ethnic groups. For example, while we are famililar with the shortcomings of traditional medical and patient education approaches in cross-cultural encounters, “me-oriented” life coaching approaches can also conflict with “we-oriented” life views of many Latino or Asian patients.
MI Includes Clear Standards for Building & Measuring Proficiency
In addition to its effectiveness and practicality, MI can be distinguished from other approaches by virtue of clear standards for training and proficiency measurement. In MI, training and proficiency go hand-in-hand. Absent proficiency, the types of outcomes demonstrated in the clinical trials on MI cannot be expected. Proficiency is rarely achieved if the time-tested, validated standards and guidelines for building MI proficiency are not followed (although learners may acquire a good understanding of the value of the approach and think they are practicing MI). MI training can, however, be targeted to the roles and settings of practitioners—another reason why it is important to choose an MI trainer experienced in health care and health management.
There have been many attempts over the years to use the Train-the-Trainer (TTT) approach to train health care practitioners in MI. To date, however, we know of no research studies or even organization case studies that show, in pre/post assessment using a standardized, validated measure of performance, that TTT is an effective approach for building MI proficiency, in any field. The lack of evidence for this approach to training is likely due to the fact that TTT was not developed to teach skill-sets as complex as those required for MI health coaching proficiency. And since MI requires such a significant reorientation for practitioners who were trained in medical and patient education models, it is essential that the trainer demonstrate expert-level MI skills to provide concrete examples of MI in practice, and to respond to the typical (and expected) concerns and challenges that health care workers express when first exposed to MI.
Success Factors for an MI Training Program
To develop an individual with the knowledge and skill for MI health coaching, it is helpful to examine the success factors for MI training. What have we learned over the years about which types of learning experiences are most effective? The success factors for an MI training program mirror best practices for any type of organization learning program: make learning practical for the adult learner by focusing on information and skills that the learner can apply on the job; provide real-life examples from the learner’s work setting; give opportunities to practice new skills and transfer to the job; and, most importantly, measure the return on investment (ROI) or effectiveness of the program. In MI, these are simplified and summarized in three steps: 1) Build knowledge through an MI immersion training; 2) Practice MI skills; and 3) Obtain skills feedback and coaching from an MI expert based on audio-recorded sample(s) of the learner’s work with an individual on a behavior change or treatment plan.
Required Trainer Skills for an Effective MI Training Program
Based on the success factors that MI researchers and practitioners have identified for MI training, we have identified the competencies and skill requirements of the MI health coaching trainer. When identifying candidates from your organization, it is important to review these trainer competency and skill requirements summarized below. Note that this sampling of skills is not an exhaustive list.
| Required Learning Component | Required Trainer Skills | |
1. Build MI Health Coaching Knowledge—using best practice learning and evidence-based MI proficiency development approaches. | Design, build and pilot a stand-up or online training curriculum that targets the spirit of MI, core MI skills and MI health coaching applications; the four-step MI health coaching framework; and typical MI applications and barriers in population health or provider settings. | |
2. Practice MI health coaching skills in real health coaching scenarios or encounters. | Demonstrate expert-level MI skills; design, deliver and de-brief workshop “real-play” sessions or online scenario-based learning or practice activities; provide on-the-fly feedback to individuals and small teams. | |
3. Build Feedback Skills based on staff work samples and standardized coding and reporting tools | Demonstrate MI coding (evaluation) skills using the MITI Coding Tool or HealthSciences Institute’s HCPA Coding & Reporting tool (both require expert-level skills in MI and coding); or the HCQI System (designed for supervisors, mentors or quality staff with or without experience or proficiency in MI or MI coding). | |
Steps for Building an MI Trainer & Mentor Team in Your Organization
Based on the above summary of MI training research and practice, along with the summary of success factors and trainer skill requirements, the process for building an MI trainer and mentor team with your organization follows. This process has been used successfully with large organizations and can be adapted for organizations of any size.
Step 1: Contract With an Expert in MI Health Coaching. Identify an MI expert or organization experienced in MI training. At a minimum, the lead trainer should be a member of the Motivational Interviewing Network of Trainers (MINT) to ensure that she or he has the general training background and proficiency to guide your team or organization. Secondly, the expert should be experienced in the use of MI in a health care setting that is similar to your own. Third, the expert should have experience working with other organizations and be able to provide evidence of successful training outcomes, along with the ability to objectively assess and evaluate the impact of their work with your organization. The expert should emphasize that training is simply the first step in an MI workforce development program; i.e., there should be a well-articulated plan for follow-up activities that will sustain improvement and build proficiency—whether face-to-face or online—per the evidence on MI proficiency development.
Step 2: Identify Internal MI Mentor Candidates. Effective mentors typically possess good leadership skills and demonstrate a commitment to professional excellence. They also show an interest in or passion for making a difference in the lives of patients through a proven approach such as MI. These characteristics are typically evidenced during the workshop, or even through online training, e.g., webinars where the MI expert can track participant responses to activities, questions, comments, etc. While it can be tempting to choose training, quality or supervisory staff for the mentor role, it is key that the individual demonstrate aptitude. Additionally, the candidates should either carry an active caseload of patients or have another way of practicing their health coaching skill-set. If the mentor cannot practice their skills, it is hard to build the required proficiency in MI to be a trainer or provide credible case studies, examples or solutions for practice challenges.
Step 3: Assess MI Candidate Aptitude and Skills. Skills assessment is an important component of the training process. Research has revealed that people cannot accurately assess their own empathy or other skills needed for a patient-centered, outcome-based approach. Therefore, it is important to use a more objective and accurate method. To assess aptitude and proficiency levels of staff, an organization should request that their expert or external vendor perform an audit or assessment, using a validated and standardized tool. This will help identify candidates who can be developed more quickly and are better suited for the mentor role. There are several tools on the market; at this time, the Health Coaching Performance Assessment tool is the only one that was developed specifically for health care, validated against the gold standard—the MITI—and has full reporting capabilities.
Step 4: Make Mentor Selections. Your MI expert partner will then provide you with a ranked list of candidates for the mentor role. Their rankings will be based on observations made during training and their performance on the validated measurement tool. Leadership will then review the list and make their selections based on individual staff and organization considerations.
Step 5: Contact Mentor Candidates. Next, a manager or supervisor will contact the individuals to assess interest in the mentor role. Remember that aptitude does not guarantee interest and passion. It can be helpful to develop and share a mentor role description so staff understand what their commitment to this role means. In formulating the mentor role, it is helpful to allot 4-8 hours each month for skill-building and mentoring activities to communicate that improving staff skill is an important priority for the team or organization.
Step 6: Build MI and Mentor Skills. Following selection, the mentor will need to participate in structured training activities to build their MI and mentor skills. Typically they would be working with the MI expert or organization during this time in an individual or team setting. They will also be assessed periodically with the assessment tool and provided expert feedback.
Step 7: Mentor Practice. Once the mentors reach the required MI proficiency level, they will start mentoring staff. It is essential that the consulting expert continue advising the mentor group during this period. Again, your MI expert will be listening to recordings of the mentor sessions and providing feedback to the mentors. This is the type of development work that may be resource intensive but typically yields some of the most tangible benefits for the mentor and organization. Think of your mentors as key players that will help you meet the outcome expectations of your customers.
Step 8: Select the Best Mentors for MI Trainer Training. MI trainers need to complete the Motivational Interviewing Network of Trainers (MINT) New Trainer Program. As application to this program is highly competitive, your leadership will need to select the best candidate(s) from the mentor pool based on MI proficiency levels, leadership, passion, and group presentation and small group facilitation skills. Solicit input from your MINT-level MI partner and request that they sponsor the individual’s application to participate in the New Trainer Program held annually. Learn more at motivationalinterviewing.org.
Step 9: Training Apprenticeship. Request that your MI trainer be allowed to co-facilitate at least one or more workshops with your MI expert trainer or organization. Your partner will evaluate their performance and provide them continued improvement feedback. Experience shows that the most successful trainers demonstrate dual expertise in both training and facilitation for different size teams and individuals.
While the process of becoming a MINT trainer may appear lengthy, keep in mind that your team of mentors is a valuable internal resource that can start providing feedback and support for all staff in as little as six months. While the MI skill-set is difficult to master, and the mentor and trainer development process can take some time, it is important to weigh the value of measurable results for attracting and retaining customers. Most organizations find that an investment in a proven, best practice approach for improving engagement and health behavior is well worth the investment of time and resources.
