A system approach to embed best practice motivational interviewing in health care : a wicked problem?

Background and Aims: Motivational interviewing (MI) is internationally recognised as an effective intervention to facilitate health related behaviour change; although, how it is best implemented and supported in everyday clinical practice is not so clear. The aim of this study is to find out: 1) how MI as an intervention is implemented (or can be implemented) in clinical practice and learning environments; 2) how MI skills are best developed and maintained in a high workload practice environment that includes students; and 3) how to ensure the sustainability of MI in clinical practice and learning environments. Methods: The first part of the study has ethics approval and used survey data collected at a conference workshop attended by 30 health professionals. The five pre-workshop questions explored whether they use MI as a clinical intervention, their confidence in using it, how MI has been implemented at the departmental level, and whether processes have been developed to support high fidelity. The four post-workshop questions and four general questions identified barriers to using MI, enablers and use of various resources that are available, and how MI can be maintained in a busy clinical environment. The second part of the study is a scoping review to identify reported barriers and enablers to implementation and maintenance of MI in health care settings. Ten studies were included and a meta-ethnography synthesis of the qualitative findings was conducted. The third part of the study integrated the outcomes of parts one and two, and synthesised them using complexity theory and a conceptual framework(s) to assist clinical educators in embedding MI in their practice and learning environment, and enhance practitioners' and students' competence and confidence in using MI as part of routine care and interprofessional practice, to optimise health outcomes. Results: MI takes place at the clinical microsystem level (departmental), whereas training is more likely to take place at the meso-level (health disciplines across the university and health organisation). Meso and macro-level related factors to be considered include professional standards and associated training requirements, local and regional health needs, acute versus chronic condition management, and associated funding. Conclusion: Successfully embedding MI in client-centred health care requires awareness of the possible barriers, and facilitating agreed guidelines and processes that not only support education, skills development and maintenance of MI, but also support interprofessional collaborative practice at the departmental or micro-level