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In an era where every organization has multiple change initiatives underway, health care is struggling to create sustained change. As someone who supports organizations when they implement new innovations — such as evidence-based guidelines, practices, and programs — much of my work is about understanding how people make change. When I came across the IHI Psychology of Change Framework white paper, I immediately recognized it as the missing piece in the puzzle of our change efforts. 

The Psychology of Change Framework presents five interrelated domains that are essential to move forward any change efforts:

The framework addresses the human component of change by considering the multiple ways in which people respond to new initiatives. I could write an essay on each component of the framework, but I find unleashing intrinsic motivation particularly compelling at a time when so much in health care focuses on rewards and punishments. The Psychology of Change white paper quotes clinical and social psychologists Richard Ryan and Edward Deci as defining intrinsic motivation as “doing something for the inherent satisfaction that engaging in the activity provides.”

Rewards, Punishments, or Intrinsic Motivation

The research is clear that when people change their behavior based on rewards and punishments, changes can happen quickly, but are often short-lived. Yet, the possibility of rewards or the threat of punishment drives so many of our mechanisms of change in health care.

Most health care professionals do what they do because they want to help people. We should tap into their innate reasons for working in health care instead of focusing on punitive actions or rewards. Ignoring intrinsic motivation is a wasted opportunity because releasing it creates momentum for change and — more importantly — greater potential for sustainability.

Tools to Unleash Intrinsic Motivation

I’m often asked about the best way to motivate people. Learning to unleash intrinsic motivation is a particularly challenging skill. I am a huge proponent of the principles of motivational interviewing. The underlying idea behind motivational interviewing is that you don’t tell people to change; instead, you help them recognize that they want to change.

Motivational interviewing is an evidence-based clinical psychology practice, but its value extends beyond the clinical context. Motivational interviewing provides key principles to follow when trying to unleash intrinsic motivation, including:

• Roll with resistance — Avoid arguing and, if resistance arises, find another way around it instead of pushing back.
• Express empathy — Use active and reflective listening to make sure you understand where the other person is coming from. Ambivalence to change is normal. When it happens, let the other person know you see their perspective.
• Avoid argumentation — Invite new ideas and perspectives, but don’t impose one perspective over the others. Shift from seeing the other person as an adversary. Instead, consider them a resource for new solutions.
• Develop discrepancy — Listen for ways in which the other person is describing goals they have that may not align with their current behavior. These are the discrepancies. Then, carefully highlight how their behavior doesn’t match their goals. The objective is to help them recognize the misalignment on their own.
• Support self-efficacy — Believing that you can change is an important motivator to change, so it’s essential to support an individual’s belief in their innate ability to achieve goals and emphasize their strengths.

Motivational interviewing also includes four key activities specifically for eliciting discussions about making change:

1. Ask open-ended questions;
2. Affirm progress and recognize strengths;
3. Practice reflective listening by paraphrasing and repeating back what’s been said; and
4. Summarize the conversation and highlighting discrepancies.

Motivational interviewing can be an asset to any change initiative. It can help you understand the underlying reasons for resistance. It provides tools to unleash intrinsic motivation, by having staff members self-identify the ways in which they want to change.

Julia Moore, PhD, is the senior director of the Center for Implementation.

You may also be interested in:

• IHI Psychology of Change Framework white paper

• Psychological Bulletin — "A meta-analytic review of experiments examining the effects of extrinsic rewards on intrinsic motivation"

• Annual Review of Organizational Psychology and Organizational Behavior — "Self-Determination Theory in Work Organizations: The State of a Science"