Implementing Motivational Interviewing

Summary

Successful implementation of MI across an organization involves practitioners being both competent in MI and integrating MI into routine practice. It is not enough for staff to attend a workshop where they are introduced to the concepts and core skills. Implementation at a system level requires commitment of leadership, finances, resources, and time combined with a multi-leveled approach to developing capacity.

Preparing for implementation

Full implementation of MI (or any other evidence-based practice) requires two things:

1. Practitioners must be able to demonstrate fidelity of practice, meaning that MI is delivered as it is intended to be delivered.
2. Practitioners integrate MI into every day, routine practice.

Both elements are important. Clients do not gain the full benefit of MI from either the practitioner who reaches fidelity but does not use MI regularly in practice or from the clinician who attempts to use MI frequently but has low fidelity.

MI can be readily integrated into existing practices, procedures, protocols, and services. However, learning and integrating MI often requires an intentional and thoughtful review of existing practices and policies because MI often requires new ways of thinking and communicating for both leaders and practitioners.

If done well, an organization can achieve full implementation into services within two to four years. Some organizations are more able to adopt and implement MI than others. Some characteristics of organizations that seem to support successful MI implementation include:

• Strong leadership with vision for quality services, willingness to invest in staff development and ability to prioritize MI implementation.
• Organizational culture of person-centeredness, client autonomy, and self-determination.
• Openness to learning and change in practitioners and supervisors.
• Low turnover rate among practitioners and supervisors with moderate to high levels of employee satisfaction.
• Internal expertise in change management with experience in quality improvement and implementation projects.

The process of implementation

Although there is no one right way to accomplish implementation, implementation researchers have identified four key stages in the process: exploration, adoption, initial implementation and full implementation.

Exploration: The purpose of exploration is to gather information in order to make an informed decision whether to proceed with MI as an organization

• Ensure there is support from the leadership.
• Form an implementation team with some expertise in quality improvement or change management, including a manager, supervisor, and practitioner “champions” of MI.
• Involve input from practitioner staff.
• Gather information and explore questions such as:

• How might MI meet clients’ needs? What is the evidence of effectiveness for MI given the organization’s specific population, services, and setting?
• How might MI fit with the organization’s mission, vision, values, and strategic goals?
• What is the capacity needed to implement MI in terms of fidelity and integration into routine practice? Does the organization have the necessary finances, resources, infrastructure, and time to engage the process?
• Are practitioners ready to engage in the necessary learning and integration? Are they willing to receive performance-based feedback on MI based on direct observation of practice? Are they willing to let go of some practices-as-usual in order to deliver MI as an evidence-based practice?
• Is leadership ready to prioritize MI implementation and maintain focus on it over time? Is leadership able to allocate the necessary resources and supports for successful integration?

Adoption: Once the decision has been made by leadership to adopt MI, the next stage is to begin preparation to build the organization’s capacity for successful implementation.

• Select practitioners for training and initial implementation that will support the initiative:  
  • Consider practitioner self-selection based on readiness to learn.
  • Implement in stages with cohorts of practitioners over time – more reluctant practitioners may become more open after observing positive experiences and outcomes of their peers. 
• Develop a coaching program:
  • Prioritize coaching practitioners in MI following training to support learning and integration.
  • Select coaches – e.g. clinical supervisors, peer mentors or external consultants.
  • Select a coding instrument for fidelity review that fits the objectives of the project – results provide the basis of feedback in coaching and evaluation of the project.
  • Develop a clear plan for how the coaching will be conducted (e.g., expectations, frequency, duration, content and process of coaching sessions, frequency of fidelity reviews, support for struggling practitioners).
  • Develop competence of internal coaches in evaluating MI practice and providing feedback.
• Train selected practitioners:
  • Provide a starting point for learning how to deliver MI with fidelity with an emphasis on skill-building, practice, and initial feedback
  • Support practitioners to connect with why MI is being implemented, not just how to do it.
• Ensure the implementation team meets regularly:
  • Assess existing strengths and areas to develop.
  • Support strategic planning with resource allocation.
  • Plan how MI will be integrated into current practices, procedures, protocols, and services.
  • Make these plans realistic and accessible for practitioners and their coaches to successfully use MI in routine practice.
• Develop policy and procedures to support fidelity review:
  • Build in strategies to assess practitioner fidelity through direct observation of practice – e.g. record audio practice samples for later review with a protocol for written client consent.
• Develop a data system:
  • Collect data from multiple sources to inform quality improvement and to assess service outcomes – e.g. practitioner fidelity review results, practitioner satisfaction with coaching, client satisfaction of MI, client outcomes of services.
  • Select relevant measures and develop user-friendly data collection procedures. 

Initial Implementation: This stage occurs when the first clients participate in MI or the new MI-informed service. Activities and tasks continue from the previous stage.

• Ensure the data system is now in place:
  • Routinely collect data from selected measures.
  • Compile practitioner fidelity results to assess overall progress, strengths and areas to be addressed in further coaching and training.
• Provide ongoing coaching to support practitioner learning and integration:
  • Focus on practitioner skill development and practice.
  • Support practitioners to work through initial discomfort with delivering a new practice.
  • Explore and resolve ambivalence with MI consistent approaches to develop confidence in MI.
• Offer advanced practice training to supplement the coaching:
  • Deepen and consolidate skills and understanding.  
• Ensure the implementation team continues to meet regularly:
  • Identify barriers of initial implementation in discussion with practitioners and coaches.
  • Communicate barriers to leadership for problem solving.
  • Identify and share initial stories of success throughout the organization to build momentum.

Full Implementation: This stage occurs when 50 percent or more of the intended client population receives MI or the new MI-informed service. The goal is to continue to support the implementation and build capacity for long-term sustainability.

• Evaluate the learning and outcomes of the initial implementation with the leadership team:
  • Decide whether to extend or scale-up the implementation to another cohort of practitioners.
  • If yes, select, training and coach the next cohort.
• Consider whether a process of certification would be helpful:
  • Recognize practitioners who repeatedly demonstrate fidelity to specified standards and consider reducing the frequency of their coaching sessions.
  • Identify practitioners who struggled to become certified and consider increasing coaching sessions.
• Build MI into organization policies and procedures, e.g.:
  • Create hiring criteria based on a pre-employment empathy screen of skillful use of reflective listening and accurate empathy.
  • Clearly state MI in job descriptions.
  • Introduce MI during new employee orientation.
  • Include MI measures in employee performance reviews.
  • Align organization reward system to incentivize MI implementation.
• Use data to conduct a thorough evaluation of the implementation effort:
  • Assess the impact of MI on client satisfaction and outcome.
  • Review whether the organization experiencing the anticipated benefits of MI.
• Regularly review evaluation results at a leadership level:
  • Decide whether to continue, change or stop the MI implementation project.

Further questions

• Why does your organization want to implement MI? What might be the benefits for clients, staff, community?
• How might MI fit or conflict with existing priorities, projects, or initiatives?
• What are your experiences with prior implementation efforts? What were some lessons learned?
• If an MI implementation project were to launch, what level of financial resources would your organization be willing to invest?

• Who are your “champions” of MI? Who might be good members of an implementation team?
• What is the current level of practitioner interest in MI?
• Who is available, internally or externally, to provide guidance and consultation as you consider MI implementation?
• How will you know you have been successful? What outcomes are you hoping to achieve by implementing MI?

References and Resources

• Ball, S. A., Martino, S., Nich, C., Frankforter, T. L., Van Horn, D., Crits-Christoph, P., Carroll, K. M. (2007). Site matters: Multisite randomized trial of motivational enhancement therapy in community drug abuse clinics. Journal of Consulting and Clinical Psychology, 75(4), 556-567.
• Fixsen, D. L., Naoom, S. F., Blase, K. A., Friedman, R. M., & Wallace, F. (2005). Implementation research: A synthesis of the literature. Tampa, FL: University of South Florida. Accessed from http://nirn.fpg.unc.edu/sites/nirn.fpg.unc.edu/files/resources/ NIRN-MonographFull-01-2005.pdf