Three Strategies for Implementing Motivational Interviewing on Medical Inpatient Units
| Status: | Active, not recruiting |
|---|---|
| Healthy: | No |
| Age Range: | 18 - 100 |
| Updated: | 1/12/2017 |
| Start Date: | May 2013 |
| End Date: | June 2017 |
Three Strategies for Implementing Motivational Interviewing on Medical Inpatient Units: See One, Do One, Order One
General medical hospitals provide care for a disproportionate share of patients who abuse or
are dependent upon substances. This group is among the most costly to treat and has the
poorest medical and substance use outcomes. Motivational interviewing(MI) is a
well-recognized, evidenced-based substance abuse treatment that has been adapted for use as
a brief intervention in health care settings.MI is applicable to many health-related
behavioral problems, and can be taught to a broad range of health care clinicians. However,
it is unclear which implementation strategies will lead to the efficient and proficient
uptake of MI in general medical settings, such as medical inpatient units.
Primary care clinicians have multiple practice demands and time constraints. New practices
have the greatest chance of being implemented if they are simple and compatible with
existing workflows and systems. Two widely used strategies to bring specialized practices
into use within general hospital settings are the "see one, do one" apprenticeship model of
training and use of consultation-liaison (CL) services. "See one, do one" has been a modus
operandi in medical education for centuries and relies upon a competency-based supervision
training approach. While it has been empirically validated in the specialty addiction field,
less controlled testing of this implementation strategy is available in general medical
settings. The apprenticeship approach requires that appropriate patients and trainers are
available with high flexibility for teaching and supervision; when applied to behavioral
counseling approaches, this may be seen as incompatible with the medical role and time
constraints of clinicians. In contrast, ordering MI through CL is a relatively simple,
minimally burdensome process and highly compatible with the way clinicians secure other
specialist services for their patients in the hospital.
We propose to conduct a randomized controlled trial using mixed quantitative and qualitative
methods to examine the effectiveness of three different strategies for integrating MI into
the practice of healthcare providers working within Yale New Haven Hospital's internal
medicine hospitalist service and other general medical inpatient units. Specifically, we
will randomize 40 healthcare providers to one of three conditions: (1) a continuing medical
education workshop that provides background and "shows" healthcare providers how to conduct
MI (the control condition, called SEE ONE); (2) a "see one, do one" apprenticeship model
involving workshop training plus live supervision of bedside practice (DO ONE); and (3)
ordering MI from CL after learning about it in a workshop (ORDER ONE). Following the
respective MI trainings, each healthcare provider will be assessed for the provision of MI
to 40 study-eligible inpatients, recruited by the research team after admission to our
general medical units.
are dependent upon substances. This group is among the most costly to treat and has the
poorest medical and substance use outcomes. Motivational interviewing(MI) is a
well-recognized, evidenced-based substance abuse treatment that has been adapted for use as
a brief intervention in health care settings.MI is applicable to many health-related
behavioral problems, and can be taught to a broad range of health care clinicians. However,
it is unclear which implementation strategies will lead to the efficient and proficient
uptake of MI in general medical settings, such as medical inpatient units.
Primary care clinicians have multiple practice demands and time constraints. New practices
have the greatest chance of being implemented if they are simple and compatible with
existing workflows and systems. Two widely used strategies to bring specialized practices
into use within general hospital settings are the "see one, do one" apprenticeship model of
training and use of consultation-liaison (CL) services. "See one, do one" has been a modus
operandi in medical education for centuries and relies upon a competency-based supervision
training approach. While it has been empirically validated in the specialty addiction field,
less controlled testing of this implementation strategy is available in general medical
settings. The apprenticeship approach requires that appropriate patients and trainers are
available with high flexibility for teaching and supervision; when applied to behavioral
counseling approaches, this may be seen as incompatible with the medical role and time
constraints of clinicians. In contrast, ordering MI through CL is a relatively simple,
minimally burdensome process and highly compatible with the way clinicians secure other
specialist services for their patients in the hospital.
We propose to conduct a randomized controlled trial using mixed quantitative and qualitative
methods to examine the effectiveness of three different strategies for integrating MI into
the practice of healthcare providers working within Yale New Haven Hospital's internal
medicine hospitalist service and other general medical inpatient units. Specifically, we
will randomize 40 healthcare providers to one of three conditions: (1) a continuing medical
education workshop that provides background and "shows" healthcare providers how to conduct
MI (the control condition, called SEE ONE); (2) a "see one, do one" apprenticeship model
involving workshop training plus live supervision of bedside practice (DO ONE); and (3)
ordering MI from CL after learning about it in a workshop (ORDER ONE). Following the
respective MI trainings, each healthcare provider will be assessed for the provision of MI
to 40 study-eligible inpatients, recruited by the research team after admission to our
general medical units.
For Healthcare provider participants:
Inclusion criteria :
- Assignment to one of the general medical inpatient units at YNHH during day-time
shifts; intensive care units will be excluded given the morbidity of patients in this
setting.
- Volunteer to serve as study clinicians, attend a workshop about MI, and possibly
receive live supervision.
- Agree to all procedures of this trial (randomization to training condition and of
assigned patients, audio recording MI sessions, and completing assessments).
Exclusion criteria:
- Have been formally supervised to use MI with patients on the units.
- Intend to give notice to YNHH that they plan to leave the hospital or are scheduled
for medical or family leave such that they will not be able to interview 40 patients
during the study period.
For patient participants:
Inclusion criteria:
- Are 18 years of age or older.
- Acknowledge use of a substance within past 28 days and meets screening criteria
consistent with substance (illicit drugs, licit drugs that are used in a
non-medically indicated fashion, alcohol, or nicotine) use disorder.
- Are willing to consent to audio recording of interview with the Healthcare provider
or CL psychiatrist.
Exclusion criteria:
- Have an altered mental status such as delirium, encephalopathy, dementia or mental
retardation or a score on the Confusion Assessment Method > 0 since this would impair
provision of consent and ability to participate
- Inability to speak English. Most of the Healthcare providers are mono-lingual English
speakers, and all MI integrity raters only speak English. We therefore do not have
the capacity to include Spanish-only speaking patients in the study.
- Stroke (that precludes participation)
- Resides in a nursing home, skilled nursing facility or Hospice Care
- Receiving palliative care
- Deaf
- Unable to speak lucidly
- Previous participation in the protocol
An information sheet was requested and approved for a subset of patient subjects. This is
due to the study being conducted within an acute medical inpatient unit, where conditions
that might limit a person's ability to sign the consent form may occasionally occur. This
subset of patients includes: patients that are physically unable to write (i.e. hand
tremors, spinal cord injury, stroke that precludes signing, broken hand, broken shoulder,
muscular dystrophy and other physical ailments preventing a patient from physically
signing), unable to see (i.e. legally blind, uncontrolled type 2 diabetes mellitus which
led to blurred vision), unable to read (i.e. patient does not have their glasses on them).
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