
==== Front
PEC Innov
PEC Innov
PEC Innovation
2772-6282
Elsevier

S2772-6282(24)00083-9
10.1016/j.pecinn.2024.100335
100335
Full length article
Co-designing a motivational interviewing training platform to enhance oncology healthcare professional communication
Dang Thu Ha thuhadang@swin.edu.au
abc⁎
Ludlow Chris a
Borle Hannah d
Alexander Marliese ef
Wickramasinghe Nilmini ghi
Burbury Kate fjm
Jayaraman Prem Prakash k
Schofield Penelope gln
a Department of Psychological Sciences, School of Health Sciences, Swinburne University of Technology, Melbourne, Victoria, Australia
b Health Services Research and Implementation Sciences, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
c Digital Health Cooperative Research Centre, Sydney, Australia
d Northern Health, Victoria, Australia
e Pharmacy Department, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
f Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, Victoria, Australia
g Optus Digital Health, La Trobe University, Melbourne, Victoria, Australia
h Department Health and Bio-Statistics, School of Health Sciences and Iverson Health Innovation Research Institute, Swinburne University of Technology, Melbourne, Victoria, Australia
i Epworth Healthcare, Victoria, Australia
j Digital and Healthcare Innovation, Peter McCallum Cancer Centre, Melbourne, Victoria, Australia
k Factory of the Future and Digital Innovation Lab, Department of Computer Science and Software Engineering, School Software and Electrical Engineering, Swinburne University of Technology, Melbourne, Victoria, Australia
l Department of Psychological Sciences, and Iverson Health Innovation Research Institute, Swinburne University of Technology, Melbourne, Victoria, Australia
m Tasmanian Health Services, Department of Health, Hobart, Tasmania, Australia
n Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
⁎ Corresponding author at: Department of Psychological Sciences, School of Health Sciences, Swinburne University of Technology, John St, Hawthorn, Melbourne, VIC 3122, Australia. thuhadang@swin.edu.au
22 8 2024
15 12 2024
22 8 2024
5 1003359 3 2024
13 8 2024
18 8 2024
© 2024 The Authors. Published by Elsevier B.V.
2024

https://creativecommons.org/licenses/by-nc/4.0/ This is an open access article under the CC BY-NC license (http://creativecommons.org/licenses/by-nc/4.0/).
Background

Oncology healthcare professionals (HCPs) using motivational interviewing may motivate and support patients with chronic illness to adhere to medications. Research of online motivational interviewing training focusing on medication adherence in cancer is limited.

Objective

Co-design, develop, and preliminarily evaluate a motivational interviewing training platform (MITP) for oncology HCPs focused on medication adherence.

Methods

We used co-design and design science research methodology to develop and test the MITP in two phases: 1) program co-design and development and 2) interactive platform design and development.

Results

HCPs expressed a high demand for a practical and tailored motivational interviewing training. MITP is an online three-hour training comprising education, roleplay videos, and formative assessments. MITP was reported to be acceptable, usable, and useful by users.

Innovation

This study used a novel approach combining co-design and design science research methodology, and digital media to develop a flexible and acceptable online motivational interviewing training focused on medication adherence in cancer.

Discussion and conclusion

Applied rigorous methodology ensured the MITP was developed to address knowledge gaps and the needs of oncology HCPs for supporting patient adherence, and to be usable and useful. Study findings may inform future research on online motivational interviewing training and its potential impact on medication adherence.

Highlights

• Need for interactive and practical online motivational interviewing (MI) training.

• Novel approach using co-design, design science research and digital media.

• The MI training platform (MITP) focuses on medication adherence in cancer.

• The MITP is acceptable, flexible, usable, and useful for healthcare professionals.

Keywords

Co-design
Medication adherence
Motivational interviewing
Online
Training
Abbreviations

Design science research methodology (DSRM)

Healthcare professional (HCP)

Learning management system (LMS)

Medication adherence (MA)

Motivational interviewing (MI)

Motivational interviewing training platform (MITP)

Unified Theory of Acceptance and Use of Technology (UTAUT)
==== Body
pmc1 Introduction

Oral anti-cancer medicines are increasingly used for their high efficacy and convenience [1,2], yet patients are required to strictly adhere to and self-manage their treatment [2,3]. Medication adherence (MA) is defined as “the extent to which patients take their medication as recommended by their health care provider” [4]. Patient adherence to oral anti-cancer medicines is low (14 %–100 %) [[4], [5], [6]], which negatively affects clinical outcomes and health resource use [[7], [8], [9]]. Patients often reported a lack of control over, and anxiety about treatment side-effects, and poor self-efficacy relating to side-effects management [10,11]. Appropriate support from healthcare professionals (HCPs), specifically, nurses and pharmacists [9,12], may improve adherence and self-management behaviours of patients [11].

Motivational interviewing (MI) is a behavioural change approach used in communication and patient engagement [13]. Compared with other behavioural change frameworks [[14], [15], [16]], MI [17], is unique in its approach. MI uses a flexible, collaborative, patient-centred counselling format, that is easily adapted for limited-resource settings [18]. It focuses on exploring patient ambivalence to treatment and evoking their self-motivation for change, instead of imposing expert advice [19], which is very important for patients who are struggling with emotional and physical challenges of cancer treatment [11,20]. This behaviour change approach has been widely and successfully used in various health contexts, e.g. smoking cessation, diet, and exercise [9,[21], [22], [23]]. Its effectiveness in improving patient-centred communication [24,25] to affect better patient outcomes, such as MA in patients with chronic illness, including cancer, has been reported in literature [9,[26], [27], [28], [29]].

Most of available MI training programs covered general or introductory aspects of MI and often presented in a traditional format, e.g. seminars and workshops [30]. Studies of a MI training for oncology HCPs that is delivered online and focuses on patient nonadherence and self-management of treatment side-effects are scarce [30,31]. Although face-to-face training might be considered an optimal approach, it often limits access due to the time required, costs, and physical attendance involved. Shifting from in-person to online training, especially during and after the COVID-19 pandemic, is likely to address barriers and provide benefits to both learners and training providers, by being more appealing, practical, sustainable, flexible, accessible, low-cost, and widely available [32].

Previous work: In our previous project, a draft MI training content, including slides and videos for oncology HCPs was created and structured in eight modules. Informal feedback from HCPs was that the training was too long, theory-heavy, and not very interactive.

Given the gap of knowledge in online MI training for oncology HCPs focusing on MA [30,33] and the project's need in improving the available draft training content, this study aimed to co-design, develop and pilot test the acceptability, usability and usefulness of its new online version, namely Motivational Interviewing Training Platform (MITP).

2 Methods

Co-design [34] and design science research methodology (DSRM) [35] were applied as overarching theoretical frameworks to develop the MITP. Co-design is an approach where designers, end-users, and stakeholders work together throughout the design development process. As result, the innovation, i.e. MITP, is developed based on the voice of end-users, i.e. HCPs, and the mutual understanding between designers and people involved. The co-design would help to enhance the acceptability, desirability and usability of the designed solution [36]. DSRM has been a leading paradigm in information system research focused on the design and implementation of innovative technologies [37]. It has been employed in different healthcare contexts [38,39] and includes four cycles (change and impact, rigor, design, and relevance) [40] and six process stages (problem identification and motivation, definition of the objective of the solution, design and development, demonstration, evaluation, and communication) [41] We adapted these 4-cycle and 6-process DSRM to direct the steps required for the design and development of the MITP (Appendix 1).

The MITP development was conducted in two phases: 1) Program co-design and development and 2) Interactive platform design and development (Fig. 1). In Phase 1, project stakeholders participated in the co-design process of the MITP Version 1. In Phase 2, the MITP Version 1 was further improved based on feedback from Phase 1 to develop the MITP Version 2, before it was tested by HCPs and final-year nursing students. A Steering Committee, comprising expertise in digital health, information technology, nursing, oncology, pharmacy, psychology, and consumer advocacy, was formed to guide the overall study.Fig. 1 Design and development phases of the Motivational Interviewing Training Platform.

Fig. 1

2.1 Phase 1: Program co-design and development

This phase consists of five DSRM process stages as described in Fig. 1. It commenced with reviewing the literature on MA in cancer, MI, and patient-centred care to identify research problems, and evaluating the existing draft MI training content to identify required improvements, in consultation with the Steering Committee (Stage 1). As results, the requirements of the new program (MITP version 1) were defined (Stage 2).

At Stage 3, co-design workshops and interviews were conducted to conceptualise the program's structure and content requirements. The program was then designed, developed, and transferred to an interactive learning system in a six-step iterative process (Table 1).Table 1 Co-design and develop the Motivational Interviewing Training Platform (MITP) version 1.

Table 1Steps	Activities	
1. Restructuring the existing training program

	• Feedback on the existing draft was compiled and classified by the research coordinator, in consultation with three experts in digital health and psychology.

• The training program was restructured: shorten the length of each module, revise training slides, and draft a filming plan.

	
2. First internal review

	• The scientific committee reviewed and provided feedback via email on the restructured training content, focusing on re-organising and re-wording slides for comprehensiveness and conciseness, and updating the filming plan.

	
3. Co-design workshops and interviews

	• Conducted online co-design workshops and individual interviews with healthcare professionals, stakeholders, and consumer representatives.

• Before the session: participants reviewed the proposed training content and filming plan.

• During the session:– Verbal consents were obtained.

– The research coordinator ran the session following an agenda.

– Nominal group technique [69] was used to democratically elicit participants' ideas/feedback relating to a) their requirements and expectations for the MITP, and potential barriers to dissemination in clinical oncology settings; and b) approaches for creating training resources that are evidence-based, appropriate, and likely effective.

	
4. Data analysis and second internal review

	• Data captured from the notes, recordings, and emails during and after workshops/interviews were analysed using both inductive and deductive processes of the thematic approach [46].– Deductive: the analysis focused on training modules.

– Inductive: the thematic analysis sought to identify the full range of healthcare professionals' needs, experiences, issues, and expectations on the MITP that arose within these themes as well as any other insights participants wanted to share [70,71].

• The analysis results were discussed with the wider research team and any disagreements were discussed and resolved by consensus [72].

	
5. Revising the training content

	• Used data from Step 4 to revise the training content and filming plan.

• New filming scripts were drafted, reviewed, and edited by a professional script writer, then filmed/re-filmed by a professional filming company.

	
6. Transferring the program to an interactive online learning platform

	• Developed slides and videos during the co-design process were imported into Storyline360 eLearning authoring software and adapted for online delivery.

• Interactive elements and formative assessment questions were added to the eLearning modules as per recommendations from the co-design process.

	

In Stage 4, the modules were published as SCORM packages and uploaded to the learning management system (LMS) (Totara version 12) of Peter MacCallum Cancer Centre, a specialised oncology hospital in Australia.

In Stage 5, member checking was performed with participants via two structured, focus group discussions. Participants first reviewed the MITP, then verbally consented and discussed their experience using the MITP in the session. This stage ensured that participant needs, expectations, and concerns in stage 3 have been addressed appropriately.

2.2 Phase 2: Interactive platform design and development

This phase consists of four DSRM process stages (Fig. 1). Feedback from the member-checking initiated the second design phase (Stage 3), when the content and technical problems detected in Phase 1 were fixed. The training materials were further refined to produce MITP version 2, in preparation for a pilot study (Stages 4 and 5). Details of the pilot study (hereafter the MITP user-testing) are presented below.

2.2.1 MITP user-testing

The user-testing was conducted to determine the acceptability, useability, and usefulness of the MITP; and to understand users' experience, expectations, and perception of the MITP to refine the platform.

2.2.1.1 Participants

Were eligible if they were a doctor, pharmacist, nurse, or junior medical staff at Peter MacCallum Cancer Centre or a Swinburne University of Technology final-year nursing student; able to access internet and mobile devices; and not participating in the MITP co-design.

2.2.1.2 Intervention and procedure

After providing written consent, participants completed a baseline survey via REDCap [42], which collected demographic data and assessed their knowledge and experience with MI. Participants accessed to the MITP for self-studying and completing formative assessments to evaluate learning acquisition over eight weeks. Data from the LMS, including the number of completions and tries in formative assessment and views, were collected for analysis.

In week 8, participants completed the adapted Unified Theory of Acceptance and Use of Technology (UTAUT) questionnaire [43,44] to assess their acceptance and use of the MITP, including five dimensions: performance expectancy, effort expectancy, social influence, facilitating conditions and behavioural intention. HCPs were asked to rate their satisfaction with MITP on a 5-point Likert scale. The UTAUT also included some open questions about HCPs' experience with medication non-adherence and their perceptions of the training (Appendix 2).

2.2.1.3 Data analysis

Quantitative data obtained from the baseline survey and UTAUT questionnaire were analysed in SPSS version 28 [45]. Descriptive statistics were used to summarise participant characteristics. Results of UTAUT questionnaire were summarised for each of the five dimensions with the percentage of HCPs endorsing Likert scale ratings. Qualitative data obtained from open-ended questions in the baseline survey and UTAUT questionnaire was analysed thematically using a comparative and predominantly inductive process following six steps: data familiarisation, codes formulation, generation of themes, themes review, defining an naming themes, and report formation [46,47]. The research coordinator (THD) led code and thematic development, which was then reviewed by a research team member (PS). All disagreements were discussed, and adjustments were made until consensus was reached.

3 Results

The results are presented in the sequence of MITP development phases and DSRM process stages as shown in Fig. 1.

3.1 Phase 1-Stage 1. Review literature and the draft MI training program, and Stage 2. Requirements of the new program

The literature review showed that despite the medication non-adherence problem in cancer being well documented [6,48], the effectiveness of interventions to address it is not well-articulated [12,49]. Patient-centred care can be an excellent advanced effort to solve challenging medication non-adherence problem [50,51], because it can empower and engage the patient in managing their own health [50]. Both share decision making, and MI are patient-centred approaches that promote patients' autonomy in their healthcare [52]. Integration of MI and share decision making can potentially provide practical and well-described methods to accomplish patient-centred care and improve patients' abilities to self-manage long-term conditions and adhere to medication, thus enhancing patients' outcomes [52].

During Stage 1 informal review, six reviewers who are experts in nursing, medical oncology, and psychology provided comments on how the content could be shortened, less theory-heavy and more interactive. Findings from the literature and reviewers' feedback were used to guide key requirements and changes for the new training program in an iterative process (Table 2). Five iterations of the MITP training requirements were produced before acceptance by reviewers.Table 2 Key feedback from informal review and changes have been made in the draft MI training content.

Table 2Feedback	Changes in the proposed training program	Example(s) of changes	
Overall	
The draft MI training content is structured in eight modules: 1) MA overview, 2) overview of the SAMSON solution, 3) foundation of communication skills, 4) patient-centred care approaches, 5) guiding change through MI, 6) telephone consultations, 7) filmed simulated roleplays and didactic instruction, and 8) final notes, which was considered as too long.	Shortened the program structure	– Modules 4, 5, 6, and 7 were combined into one module (motivational interviewing (MI).

– The estimated completion time of the MITP was reduced from 5 h to approximately 4 h.

– Modules were labelled alphabetically instead of numbers.

	
The training was theory-heavy	Simplified concepts and content	Removed some slides with in-depth concepts and content.	
The slides were wordy and weren't interactive	Revised wordy slides and made them more interactive.		
Module 1-Medication adherence (MA) overview and Module 2- Overview of the SAMSON solution	
The length of some videos was quite long (over 3 min)	Shortened these videos to less than 3 min		
The training could benefit all healthcare professionals (HCPs) (not only nurses)	Applied this suggestion throughout the training content	Changed ‘nurses’ to ‘HCPs’	
MI teleconsultations could be delivered via telehealth (not only phone)	Change ‘phone’ to ‘telehealth/phone’	
Modules 4, 5, 6 and 7 on MI	
Both shared decision-making and MI are patient-centred care approaches that can help support MA	Integrated share decision making in the training content		
The modules were too theory-heavy, e.g. the spirit and process of MI	Shortened this content		
These modules were very long, therefore, some ways to summarise key concepts would be helpful	Created a summary slide at the end of module D		

In the proposed program, the eight modules were reduced to five: A) medication adherence overview, B) overview of the medication adherence intervention solution, C) foundation of communication skills, D) motivational interviewing, and E) wrap-up. Modules were structured consistently, starting with aims and objectives, followed by learning content and ending with references. Text within each module was significantly reduced by removing content that was deemed optional/superfluous. Additional interactive elements were added to the modules, and formative assessments were revised and integrated into the modules' content.

3.2 Phase 1-Stage 3. Co-design workshops/interviews and MITP version 1 development

3.2.1 Co-design workshops and interviews

A total of 17 individuals participated in two co-design workshops and four were interviewed. Five participants attended both workshops. Their characteristics are presented in Table 3.Table 3 Total number of participants in each stage of the Motivational Interviewing Training Platform project.

Table 3	Phase 1 – Stage iii: Co-design workshops and interviews	Phase 1 – Stage v: Member checking	Phase 2 – Stage iv and v: User testing	
Medical oncologist, n (%)	3 (18.8)	1 (9)	13 (27.7)	
Nurse, n (%)	3 (18.8)	3 (27)	10 (21.3)	
Consumer representative, n (%)	2 (12.5)	2 (18)		
Digital health researcher, n (%)	2 (12.5)	1 (9)		
Pharmacist, n (%)	2 (12.5)	1 (9)	13 (27.7)	
Psychologist, n (%)	2 (12.5)	2 (18)		
Health educator, n (%)	1 (6.3)	1 (9)	1 (2.1)	
Information technology specialist, n (%)	1 (6.3)			
Dietitian, n (%)			1 (2.1)	
Clinical trial staff, n (%)			1 (2.1)	
Project manager, n (%)			1 (2.1)	
Nursing student, n (%)			7 (14.9)	
Total, n (%)	16 (100)	11 (100)	47 (100)	

Most participants acknowledged the challenge of MA in oral cancer treatment. They commented that MI is “a great evidence-based patient-centred behavioural change approach”(a pharmacist), “making their [the HCP's] job easier, less stressful and better connection to the patient” (a radiologist), could improve “treatment experiences and outcomes” (a consumer representative), and that MI consultation “could be done by a pharmacist or a nurse…and embedded in routine care” (a haematologist).

Participant feedback indicated a general acceptance of the revised structure of the training, with roleplay videos receiving particularly positive feedback: “the content was excellent” (a consumer representative) and “really interactive” (a nurse); “the structure is really great… It provides a nice overview of all core topics from start to finish” (an education officer); and “videos are great because they show people how to do and not to do something when engaging with patients” (a consumer representative). Six roleplay videos showcased the six most common medication non-adherence scenarios in clinical settings (doubt of therapy, forgetfulness, taking medication while on holiday, misconception about cancer treatment, side-effects intolerance, and toxicity consciousness) and demonstrated how to use MI skills to address the medication non-adherence barriers.

Suggestions and areas for improvement identified during the co-design process included: a) further need to shorten the content, b) re-filming MI videos; c) inclusion of roleplay videos and examples including patients from diverse backgrounds, e.g. English as a second language; d) inclusion of content addressing communication with carers and family about MA; and e) inclusion of scenarios and examples on how to utilise MI during video-based telehealth consultations.

A consensus was made among participants that online training has advantages over traditional in-person training, and the hospital LMS could be a suitable educational online platform to deliver MI training in the user-testing study. The main barriers to the training delivery were also discussed. ‘Time constraint’ was flagged as a key challenge in the training uptake. Besides, participants highlighted the diverse training needs of different clinicians within healthcare environments. To address these, participants suggested splitting the program to core and optional modules, and developing a one-page key-point summary with key points as an add-on for learners who require only rapid refresher training. The summary can be printed as a ‘cue card’ for HCPs to use when delivering MI consultations. Table 4 Summarises proposed changes and improvements as results of the co-design.Table 4 Key feedback from co-design workshops, interviews and focus groups, and changes have been made in the Motivational Interviewing Training Platform Versions 1 and 2.

Table 4Feedback	Changes in MITP Version 1	Changes in MITP Version 2	
Structure of the training program and modules	
Addressed the ‘time constraints’ barrier to training	The motivation interviewing training platform (MITP) was restructured into core modules (C, D, and E) and optional (A and B)		
Increased the training flexibility for different learners' availability and needs	– All module was designed to be a stand-alone module so that learners don't have to visit other modules.

– A key point reminder card was developed to summarise the main motivational interviewing (MI) content.

	Applied learning management system (LMS) navigation function to direct learners to their interested section	
An introduction, learning outcomes and a summary would be helpful for learners	This new content was added to all modules.		
Content of slides	
Broaden MI context beyond medication adherence (MA)	Introduced MI application in different healthcare settings.		
Improved the engagement of module C	Applied features of Storyline360 eLearning software to make the slide less info-heavy and more interactive		
Content of videos	
Improved the engagement of videos on MI	Videos re-filmed by a research team member who is a psychologist		
Module E needed to be more substantial		Moved six roleplay videos from module D to module E.	
Included some new content in roleplay videos, e.g. patients from diverse backgrounds, carers' and family's involvement in MA, use of video-based telehealth in the clinical setting	Filmed new videos with examples of English as a second language, engaging carers in MA, and use of telehealth in MA consultation		
Mode of training delivery	
Used LMS to deliver the MITP	MITP was uploaded to the hospital LMS and accessible to all hospital's HCPs		
Other changes	
Improved the content's consistency		Edited all slides by a research team member who has experience with editing	
Avoided jargon in the content	
Improved usability of the platform		An experienced hospital education officer involved in managing the MITP on LMS provides detailed instructions on how to study the online MITP to learners.	
Mechanism to motivate learners' uptake of the training		A certificate of completion was issued to learners	

3.2.2 MITP version 1 development

Feedback from the co-design was incorporated to develop the final MITP Version 1. The three-hour online training comprised three core modules, two optional and a one-page summary sheet (Table 4). A total of 12 videos were edited, 16 were re-filmed and 10 were newly developed (Appendix 3). Formative assessments were provided within and at the end of each module to reinforce learning and to self-assess knowledge and skills acquired. Table 5 summarises the main differences between MI training versions.Table 5 Key differences between Motivational Interviewing training versions 1 and 2.

Table 5	Draft MI training content	MITP Version 1	MITP Version 2	
Target users	Nurses	HCPs	HCPs	
Length of training	Approximately 5 h	Approximately 4 h	Approximately 3 h	
Number of modules	8	5 stand-alone modules
(Core modules: C) foundation of communication skills, D) MI, and E) wrap-up
Optional modules: MA overview and B) overview of the SAMSON intervention solution)	Same as Version 1	
Module structure	• Content (slides, videos, formative assessments)

• References

	• Introduction

• Learning outcomes

• Content (slides, videos, formative assessments)

• Summary

• References

	• Overview

• Aim and objectives

• Learning outcomes

• Content (slides, videos, formative assessments)

• Summary

• References

	
Content	Slides and videos	• Slides were shortened, more concise, and interactive, less theory-heavy, and more practical

• Shared Decision Making patient-centred approach was added

• Videos were shortened, re-filmed and newly filmed

• One-page summary was added

• Storyline 360 eLearning software was used to increase the interactivity of training

	• Module E is more substantial with six roleplay videos

• Slides and videos were further edited

• Support from the hospital education team in online educational system management

	
Mode of training delivery	Undefined	Online	Online via hospital learning management system	
Certificate of completion	No	Yes	Yes	
Abbreviations: HCP (Healthcare Professionals), MI (Motivational Interviewing), MITP (Motivational Interviewing Training Platform).

3.3 Phase 1 - Stages 4 and 5. Upload MITP Version 1 to LMS and member checking

The course was uploaded to the hospital's LMS for member checking (focus group). Eleven out of 17 participants attending the co-design workshop participated in the member checking process (Table 3). In the focus group, participants appraised the MITP Version 1 and found it to be in concordance with their suggestions, with some minor corrections suggested for MITP Version 2 (Table 4, Table 5).

3.4 Phase 2 - Stage 3. Improve MITP Version 1 and develop Version 2

Based on feedback from the member checking, MITP version 2 was developed for the next stage – MITP user-testing. A detailed description of MITP version 2 is in Appendix 4.

3.5 Phase 2 - Stages 4 and 5. MITP user-testing

3.5.1 Participants

For the user-testing, 47 HCPs and nursing students participated and completed baseline surveys. Of them, 34 (72.3 %) completed the training and 33 (70.2 %) completed post-study surveys. Four participants (2.1 %) withdrew from the study, because of workload.

The median age of participants was 38 years (range = 25–69), and most were female (n = 37; 78.7 %). Doctors and pharmacists were the most common profession (n = 13; 27.7 % for each group), followed by nurses (n = 10; 21.3 %), and final-year nursing students (n = 7; 14.9 %). Thirteen (27.6 %) and 25 (53.2 %) of participants had less than one year and five years of working experience, respectively (Table 6).Table 6 Demographics of the Motivational Interviewing Training Platform user testing participants.

Table 6Characteristics	Participants (n = 47)	
Age (years)	
Median (range)	38.0 (25.0–69.0)	
Sex, n (%)	
Male	10 (21.3)	
Female	37 (78.7)	
Country of birth, n (%)	
Australia	28 (59.5)	
Canada	1 (2.1)	
Iran	1 (2.1)	
Ireland	1 (2.1)	
Italy	1 (2.1)	
Malaysia	2 (4.3)	
Myanmar	1 (2.1)	
New Zealand	1 (2.1)	
Singapore	2 (4.3)	
South Africa	2 (4.3)	
South Korea	2 (4.2)	
Sri Lanka	2 (4.3)	
Taiwan	1 (2.1)	
UK	1 (2.1)	
Vietnam	1 (2.1)	
Language spoken at home, n (%)	
English only	32 (68.1)	
English and other language(s)	15 (31.9)	
Organisation, n (%)	
Peter MacCallum Cancer Centre	40 (85.1)	
Swinburne University of Technology	7 (14.9)	
Experience (years)	
Less than 1 year	13 (27.6)	
1–5 years	25 (53.2)	
6–10 years	5 (10.6)	
More than 10 years	4 (8.5)	
Employment status	
Working full-time (at least 38 h per week)	29 (61.7)	
Working part-time (less than 38 h per week)	11 (23.4)	
Casual	0 (0)	
Studying	7 (14.9)	

3.5.2 Participant knowledge and experience with MI (baseline survey)

When asked about their experience with MI training, 26 participants (55.3 %) reported having heard of it. However, only 3 (6.4 %) had received training in this skill, and that was over six years ago. The MI training attended ranged between 8 and 10 h. These participants expressed a desire for refresh training on all aspects of MI. Six (12.8 %) claimed that they occasionally used MI to consult patients in the contexts of alcohol reduction, drug dependence reduction, lifestyle changes, MA, nutritional adequacy, or smoking cessation. Four (8.5 %) mentioned that consistent and regular follow-ups from HCPs, using MI skills, could help promote patients' adherence.

Regarding understanding MI techniques, most gave correct answers to the statements on the benefit of reflection (n = 41; 87.2 %), and the advantage of talking about people's own experience over instructing them what to do (n = 37; 78.7 %). Nearly all participants (n = 44; 93.6 %) were aware about the “contemplation stage of behavioural change”. Despite this, only 19 (40.4 %) correctly answered the question about the importance of “listening and asking questions”, and two (4.3 %) knew what “change relapse” means (Fig. 2).Fig. 2 Correct responses of participants before and after the motivational interviewing (MI) training.

Fig. 2

3.5.3 UTAUT (post-training survey)

A summary response from participants to the five UTAUT dimensions; their experiences with medication non-adherence issues and management; and experiences, expectations, and perceptions of the MITP are presented below, with full details in Appendix 5. Fig. 3 presents participants' key opinions about the MITP.Fig. 3 User testing participants' opinions about the Motivational Interviewing Training Platform (MITP) (n = 33).

Fig. 3

3.5.3.1 Performance expectancy

The MITP was found to be useful by almost all participants (n = 31; 94.0 %) as it enabled their two-way therapeutic communication with patients and increased their chance of supporting patient MA (n = 33; 100.0 %).

3.5.3.2 Effort expectancy

The MITP was found easy to use (n = 26; 78.8 %). Its presentation was clear, and content was understandable (n = 32; 97.0 %). Most participants could easily navigate the training content and assessments (n = 29; 87.9 %), yet two (6.0 %) struggled with using the platform.

3.5.3.3 Social influence

Participants commented that their use of MITP would be influenced by their senior managers (n = 30; 90.9 %) and colleagues (n = 31; 93.9 %). They wished to receive hospital support to utilise the MITP (n = 30; 90.9 %).

3.5.3.4 Facilitating conditions

Most participants were confident that they had adequate knowledge (n = 30; 90.9 %) and resources (n = 28; 84.9 %) to take the training. Nevertheless, half of them were concerned about the availability of help when having difficulties with using the MITP (n = 17; 51.5 %).

3.5.3.5 Behavioural intention

MI knowledge improvement was reported among learners (n = 32; 97.0 %). Most participants (n = 30; 90.9 %) planned to use MI skills in their future clinical practice, because they felt confident (n = 29; 87.9 %) and believed that the skills could help them in supporting patients' MA (n = 31; 93.9 %). Over two-thirds of participants would recommend the course to their peers.

3.5.3.6 Participant experience with medication non-adherence issues and management

HCP participants experienced patient non-adherence with prevalences of 18.2 % (daily) to 39.4 % (weekly). To deal with this problem, their strategies varied from doing nothing (n = 1; 2.1 %); providing resources to assist MA, e.g., handouts (n = 4; 8.5 %); education, using own-experience behavioural change techniques (n = 21; 44.7 %); or using some techniques similar to MI (n = 3; 6.4 %). Notably, three participants (9.1 %) acknowledged that they often directed patients, rather than letting them come up with their solutions. Most participants (n = 21; 75.0 %) who had tried to improve patients' MA, perceived that the effectiveness of their strategies was quite limited. After attending the training, participants commented that using MI may change patients' behaviour in a non-confrontational way and improve HCP-patient relationships. Despite this, challenges for applying MI in clinical practice, such as time constraints and language barriers were also discussed. In addition, it was noted that the delay and difficulty in quantifying the results of MI might discourage HCPs from using these skills.

3.5.3.7 Participant experience, expectation, and perception of the MITP

Overall, participants had very positive experiences with the MITP. They commented that the training platform was “excellent” (P16, P33 and P35), “clearly presented” (P16) and “based on evidence” (P33). The content and roleplay examples were “great” (P1, P3 and P8), “comprehensive” (P8), “thorough without being too heavy” (P13), and videos were “engaging and relatively short” (P16). Formative assessments were “clear and sound” (P13). Various formats and methods were used to deliver content. The course was “easy to follow” (P4, P16, P2 and P44), and “useful in practice” (P4, P15 and P34). Participants appraised the MI technique as a “patient-centred” (P4, P24 and P43), “collaborative” (P2), and an “empathic and non-judgemental” (P12 and P15) approach that can “engage” (P15 and P24), “avoid didactic conversations” (P1) and “empower” patients (P7), which is “extremely helpful” (P16 and P20) in “improving MA” (P31). One participant wished for the MITP to be “mandatory training for all medical, nursing and allied health staff” (P31).

However, several participants experienced technical issues when watching videos on their mobile devices. Two learners mentioned that the training repeated concepts that they had learned before (P6 and P10). Some participants suggested either developing a shorter version of MITP for busy clinicians or splitting the longest module (D) into smaller parts. Two participants wished to have more roleplay scenarios on how MI can be used in contexts other than MA in the next version of the MITP.

3.5.4 Participation and performance (LMS reports)

Data retrieved from the LMS showed very high engagement and performance from learners in the user-testing (Table 7). The five questions about the MI techniques in the pre-training survey were repeated as part of formative assessments. Almost all participants (97.1 %) provided correct answers to these five questions in their first attempt (Fig. 2).Table 7 Learner participation in the Motivational Interviewing Training Program and their performance⁎ (n = 34).

Table 7Participation and performance	n (%)	
Participation	
Learner view	1376	
Learner post	661	
Completion	
Module A – Medication adherence overview (optional)	31 (91.2)	
Module B – Overview of the SAMSON intervention solution (optional)	30 (88.2)	
Module C – Foundation of communication skills (core)	31 (91.2)	
Module D – Motivational interviewing (core)	33 (97.1)	
Module E – Wrap-up (core)	34 (100)	
Summary sheet (optional)	10 (29.4)	
Formative assessment performance	
Module C – passed in the first attempt	29 (85.3)	
Module D – passed in the first attempt	33 (97.1)	
Module E – passed in the first attempt	34 (100)	
⁎ Data retrieved from Peter MacCallum Cancer Centre's Learning Management System between November 2022 to February 2023.

4 Discussion and Conclusion

4.1 Discussion

Research has shown that medication nonadherence is a challenge in cancer care [4,6]. Oncology HCPs, such as nurses and pharmacists, are uniquely positioned to promote MA [53]. Their communication style can associate with patients' adherence behaviour [54]. Despite this, oncology HCP approaches to address the medication non-adherence problem are fragmented, mostly based on their own experience, and not very effective [12,55], which was also one of our findings. The ‘expert style’ of communication is still dominant in oncology clinical practice, that may undermine truthful responses regarding patients' treatment compliance and negatively affect their treatment outcomes [56]. Empathetic practitioner communication, as a principle of MI [21], can reduce patient apprehensions regarding medical treatment, fostering trust and discouraging discontinuation [57]. MI could also potentially increase patients' self-efficacy in treatment management, increase their satisfaction with care and fill the current gaps in cancer care by providing continuous, comprehensive and personalised care [9]. Our study revealed that HCP participants lacked MI knowledge and experience, and desired for a comprehensive MI training. The developed MITP can help to address these gaps in knowledge [25] by equipping oncology HCPs with a full training program on patient-centred communication approaches that could be used in their clinical practice, for instance, to promote patients' adherence to medications.

Previous reviews found that MI training programs were mostly provided in the form of workshops, lasting 1–3 days [25]. However, this study emphasised time constraints as a major barrier to MI training implementation in clinical settings, which was mentioned in a few studies [58]. HCP participants expressed the need for an MI course that was short, concise, interactive, practical, and tailored to their various needs and availabilities. In our study, this unmet need was addressed by the development of a fully digital MI training. Research has shown that the effectiveness of online MI training is similar to face-to-face [59]. Moreover, it can provide greater flexibility to learners in terms of time, study environment, and location without requiring extra costs and resources [32,59,60].

Study's results showed that the online program was well received by all study participants. Learners found the MITP usable and useful. Most of them wanted to implement MI skills in their daily practice and indicated that they may recommend it to their colleagues. Furthermore, their perceived knowledge, confidence, and skills to apply MI technique in clinical practice, particularly in improving patients' adherence to medication, were very high post training. Participants expressed the desire for the MITP to be provided to all clinical staff in the hospital. Although the training's efficacy was not included in the study objective, formative assessments showed that there was significant improvement in the MI knowledge among participants. These initial results are very encouraging, indicating the potential of integrating the MITP as part of teaching curriculum in medical schools or on-the-job training programs for HCPs in the hospital and beyond.

This study has some limitations. As the primary aims of user-testing were assessing acceptability, usability and usefulness, the study was not designed to measure effectiveness of the MITP in changing clinical behaviours. In our next study, the MITP will be delivered together with a mobile app [61] in a pilot randomized controlled trial to test the acceptability, feasibility and potential effect of the multi-component digital medication adherence solution. In addition, most participants in the study were from a metropolitan specialised oncology hospital in Australia, which may not represent other oncology settings. Further research can extend the evaluation of MITP in different healthcare settings.

4.2 Innovation

This is one of the first studies to use a co-design approach and DSRM in the development of a novel digital intervention aimed at improving communication and behavioural change knowledge and skills for HCPs in oncology, focusing on MA. The co-design method enables stakeholders of the training, especially end-users (HCPs), to be involved in the very early stages of idea conception and in designing the training program [62]. Through this collaborative effort and partnership with researchers, HCPs shared their experiences, expectations, and perceptions about the MITP, and contributed to the design and development of the intervention, which ensured that the training program was based on their needs [62,63]. Throughout the co-design process, the areas for improvement of the draft MI training content were addressed. Compared to its previous version and available MI training programs, the final MITP is shorter, more concise, flexible, interactive, and practical [25].

DSRM is a powerful tool for improving methods in education research, tackling challenges in teaching and learning [64] and potentially improve the design of learning materials [65]. This method has been employed in developing education programs [65] in different healthcare contexts [38,39,66] and in designing and implementing innovative health technologies [37,39], yet its application in MI online training is scarce. The use of co-design approach and DSRM in the development of MITP resulted in high acceptance and use of the digital platform among HCP users. Detailed investigation on the application of co-design and DSRM in the MITP development in this study enhances its rigor and transparency, which help to fill the gap of knowledge on how a standard MITP training can be designed and developed [25]. Moreover, results from our study can be used as a reference for researchers who want to develop a similar online MI training in other contexts or a digital training for HCPs in general.

In this study, technology, e.g. SCORM e-learning software and digital media, was used in the design and development of MITP to help deliver training content interactively and consistently. Although digital media, e.g. audios and videos are increasingly used in healthcare training as powerful teaching tools [67,68], to the best of our knowledge, there are no roleplay videos that were co-designed and developed specifically focus on applying MI techniques to address real world barriers to medication non-adherence and enable patient self-management skills for treatments side-effects. These videos were considered to be the most ‘favourite’ content in the MITP by HCP participants. Technology also allowed learners to focus on the content of their individual need based on their availability, rather than complete the entire training course at one fixed time. The developed MITP was delivered via the official education and training channel of the hospital. As the ultimate aim of MI training is changing clinical practice of oncology HCPs on a large scale, this mode and modality of delivery could be suitable in other clinical oncology contexts, given its high accessibility [32,60].

4.3 Conclusion

Oncology HCPs have training needs in patient-centred approaches, such as MI, to provide support to patients when addressing challenges, for example, MA. The MITP was co-designed, developed, and pilot-tested on HCPs. The training was found to be acceptable, usable, and useful among users. The present study not only addresses the gap of knowledge on how online MI training can be rigorously designed and tested [32], but also fulfils the urgent need to improve MA in oncology practice. Findings from this study can be used to inform future research to examine the application of MITP in clinical practice and its potential impact on health outcomes of patients.

Ethical approval

Ethics approvals for the study were granted by the Peter MacCallum Cancer Centre's (#HREC/84192/PMCC) and the Swinburne University of Technology's Ethics Committees (#20226428-9543) in March 2022.

Funding

This work was supported by the Digital Health Cooperative Research Centre Limited (DHCRC), 10.13039/501100001781 Swinburne University of Technology , and 10.13039/501100004224 Peter MacCallum Cancer Centre (project DHCRC-0043 ). DHCRC is funded under the Australian Commonwealth's Cooperative Research Centres (CRC) program. THD is supported by the Australian Government Research Training Program Scholarship. The sponsor had no influence on the study design or the collection, analysis, and interpretation of data. The final decision to include the comments and submit the manuscript for publication was made only by the authors.

Credit authorship contribution statement

Thu Ha Dang: Writing – original draft, Project administration, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. Chris Ludlow: Writing – review & editing, Resources. Hannah Borle: Writing – review & editing, Resources. Marliese Alexander: Writing – review & editing, Resources, Methodology. Nilmini Wickramasinghe: Writing – review & editing, Supervision, Resources, Methodology, Funding acquisition. Kate Burbury: Writing – review & editing, Supervision, Resources, Funding acquisition. Prem Prakash Jayaraman: Writing – review & editing, Supervision, Resources, Funding acquisition. Penelope Schofield: Writing – review & editing, Supervision, Resources, Methodology, Funding acquisition.

Declaration of generative AI and AI-assisted technologies in the writing process

None declared.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Appendix A Supplementary data

Supplementary material 1: Adapted Four-Cycle and Six-stage Design Science Research Methodology of the Motivational Interviewing Training Platform

Image 1

Supplementary material 2: Motivational Interviewing Training Platform Post-intervention Questionnaire

Image 2

Supplementary material 3: Training audios and videos of the Motivational Interviewing Training Platform version 1

Image 3

Supplementary material 4: Description of the Motivational Interviewing Training Platform version 2

Image 4

Supplementary material 5: Participant acceptance and use of the Motivational Interviewing Training Platform

Image 5

Data availability statement

The data that support the findings of this study are available from the corresponding author, THD, upon reasonable request.

Acknowledgments

We thank all the HCPs, nursing students, health educators and consumer representatives for their cooperation in this study.

Appendix A Supplementary data to this article can be found online at https://doi.org/10.1016/j.pecinn.2024.100335.
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