1. Developing a competency framework for motivational interviewing Why? How? Where? …..and what’s next? Elizabeth Cornwallis School of Health Sciences

2.  Teaching Fellow in School of Health Sciences  Background in nursing, public health and health improvement  Practising motivational interviewing and training/educating health and social care professionals in its use for more than 15 years  Member of international Motivational Interviewing Network of Trainers (MINT)  Also a member of UK Society for Behavioural Medicine, UK Faculty of Public Health and International Positive Psychology Association

3.  Why the competency framework was developed  How it was developed  - research methods, results and potential use of the findings  - limitations and recommendations for further research  Where it is being used (and how)  What’s next?  -ideas, questions and suggestions for the next steps in development of this tool

4.  Miller and Rollnick (2009) - clarifying the boundaries and competences of therapies such as motivational interviewing (MI) can promote quality assurance in scientific research, clinical practice, and training.  Studies and reviews of MI training - Madson et al (2009 & 2012) and Soderlund et al (2011) concur, but identify a lack of consensus among MI trainers about what elements are essential in learning MI. A recurring theme in recent MI literature:  The need for a learning framework specifying essential competences for effective motivational interviewing (Rosengren, 2009; Madson et al, 2009; Soderlund et al, 2010 and Madson et al, 2012)

5. “ Many questions remain about learning MI including what elements are essential …and which are superfluous?” “The answers would provide useful data to inform the methods for teaching and learning MI.” Rosengren, D.B. (2009) Building Motivational Interviewing Skills: a practitioner workbook

6. This reflects government and health service policy in the UK where competency frameworks are increasingly used in education and workforce development (Skills for Health, 2011, Department of Health, 2004). A competency based learning framework could be of great value in informing the effective development, delivery and evaluation of high quality MI practice, training and research programmes The (version 1) competency framework for motivational interviewing was based on research carried out as part of a Master’s degree dissertation

7. Mixed methods were used in this study. Following a systematic review of relevant literature, potential MI competences were identified from a range of key documents. (e.g. Research into how MI works, MI training research, tools for assessing MI proficiency, other competency frameworks) The potential MI competences were incorporated into a draft competency framework The four processes of MI articulated by Miller and Rollnick (2010) were used as broad domain headings 1. Engaging 2. Guiding 3. Evoking 4. Planning

8. Domain 1 Engaging – the relational foundation (person-centred style, use of Open Questions, Affirmations, Reflective Listening and Summarising) Domain 2 Guiding (agenda setting, finding a focus, information and advice) Domain 3 Evoking – the transition to MI (selective eliciting, selective responding, selective summaries) Domain 4 Planning-the bridge to change (negotiating a change plan, consolidating commitment) Domain 5 Generic competences (e.g. professional and ethical practice) Domain 6 Meta-competences (ability to call on relevant aspects of MI knowledge and skills to plan and, where necessary, adapt the intervention to the needs of individual clients).

9. Domain 1 Engaging – the relational foundation Element B : Client Centred Counselling Skills Item  B1 Open Questions: Uses a range of open-ended questions to seek information, invite the client’s perspective or encourage self-exploration of the client’s thoughts and feelings towards the topic.

10. A modified Delphi process was then used to elicit the views of an international panel of motivational interviewing experts (n=20) on:  whether any of the competences ought to be reworded  whether any essential competences were missing  whether any competences should be removed from the framework Results:  Half of the expert panel did not suggest any changes to the wording of the competences or identify any missing competences and 75% did not feel that any of the competences should be removed.  Suggested changes from the other panel members were included in the second round Delphi survey.  Consensus was reached on two of the suggested changes and the draft competency framework was revised accordingly.

11. Changing the name of Domain 2 from guiding to focusing This reflected the latest thinking in the development of MI and was covered in Miller and Rollnick’s subsequent text on MI (Published -October 2012) Changing the wording of item G1 (in Domain 3) From Highlights discrepancies between clients’ current behaviour and their goals, values or self–perceptions To Explores discrepancies between clients’ current behaviour or situation and their goals, values or self– perceptions Reflects client centred approach and reflects discussions within the international MINT about aspiration for specific behaviour change versus equipoise.

12. The results of the Delphi process, together with expert panel members’ comments such as “This is very well done, thorough, and reflects the state-of-the art where MI currently is and is heading.” indicate that the framework may be acceptable to its intended audience. Workshop participants at the MINT Forum in Sheffield and UK MINT meeting in Cardiff in 2011 identified the following possible uses of the competency framework tool:  Assessing learning needs, designing and evaluating training and education programmes.  Quality assurance in clinical practice, designing research interventions.  Structuring supervision conversations  Mapping against other competency frameworks  Engaging decision makers and funders  Accreditation/certification in practice learning and training

13. Limitations of the Delphi process include:  The sustained time and commitment needed from participants.  Lack of universal scientific or professional guidelines in Delphi use. Other limitations include:  Small scale study carried out by a single researcher within a short timescale- limited the amount of Delphi survey rounds.  One researcher - so it was not possible to check inter-coder reliability when analysing themes in qualitative data.  Some issues e.g. potential overlap between competences and which competences are appropriate at beginner or advanced levels could not be addressed in this small scale study.

14.  The issue of potential overlap between competences  Which competences might be appropriate at beginner or more advanced levels of learning MI.  How the competences could best be used to inform the development of high quality MI practice, training and research

15. The competency framework was first presented at the international motivational interviewing conference in Venice (2012) Further presentations have taken place at the UK Society for Behavioural Medicine conference in Manchester (2012) and at the Motivational Interviewing Network of Trainers forum in Krakow (2013).

17.  To re-design both face to face and blended MI training at introductory, intermediate and advanced levels (to be congruent with MI 3). - UK &Italy.  Part of resource pack for international MINT Training of New Trainers. - International  To assess trainees MI practice as part of a research study using MI with stroke patients – Cardiff  Developing a new trainer competency instrument- USA.

18.  Review latest research and expert opinion on MI since the framework was first developed.  Consider how this framework could/should be developed, what further research is needed?  Who might undertake this and how?

19. Come up with ideas, suggestions or questions for how this tool could/should be developed.

20. Hard copies of the competency framework are available here today. For copies of the conference paper or a copy of the dissertation please contact Liz Cornwallis email elizabeth.cornwallis@stir.ac.uk info@cornwallisassociates.co.uk

22. Madson et al (2009) Training in motivational interviewing: a systematic review. Journal of Substance Abuse Treatment, 36 pp.101-109. Madson, M. B., Lane, C., & Noble, J. J. (2012) Delivering Quality Motivational Interviewing Training: A survey of MI trainers. Motivational Interviewing: Theory, Research, Implementation, Practice. [Online]. Available at: http://mitrip.library.pitt.edu/public/MITRIPV1N1.pdf (Accessed:12 June 2012)http://mitrip.library.pitt.edu/public/MITRIPV1N1.pdf Miller, W. R., & Rollnick, S. (2009) ‘Ten Things that Motivational Interviewing Is Not.’ Behavioural and Cognitive Psychotherapy, Behavioural and Cognitive Psychotherapy, 37 pp129-140 Miller, W.R. & Rollnick, S. (2010) What makes it motivational interviewing? [Presentation to Second International Conference on Motivational Interviewing, Stockholm, Sweden]. 6 June Rosengren, D.B. (2009) Building motivational interviewing skills: a practitioner workbook. New York: The Guilford Press. Skills for Health (2011) Competences/National Occupational Standards [Online]. Available at: http://www.skillsforhealth.org.uk/about-us/competence-nos-section/National-Occupational- Standards-NOS-FAQ.aspx (Accessed: 4 January 2011) http://www.skillsforhealth.org.uk/about-us/competence-nos-section/National-Occupational- Standards-NOS-FAQ.aspx Soderlund et al (2011) A systematic review of motivational interviewing training for general healthcare practitioners. Patient Education and Counselling,84 (1) p.p.16-22. References