Too Busy, Too Bored, Too Burnt-Out:

Practical Theory-based Tools to Win

Back the Unmotivated LearnerKarin B. Gray, MD

Whitney L. Browning, MD

Sarah F. Denniston, MD

H. Barrett Fromme, MD, MHPE

Natalie G. McKnight, MD

Kira A. Molas-Torreblanca, DO

Katie E. Pestak, DO

Disclosures

We have no relevant financial relationships with the manufacturers of any commercial products and/or providers of commercial services discussed in this CME activity.

We do not intend to discuss an unapproved/investigative use of a commercial product/device in our presentation..

Goals and Objectives

• Practice Motivational Interviewing skills to re-engage the unmotivated

learner.

• Apply Self-Determination Theory to the unmotivated learner and their

environment.

• Examine tools and strategies known to engage Millennial learners.

Roadmap

• Introductions

• Motivational Interviewing (large group)

• Motivational Interviewing (pairs)

• Self-Determination Theory (large group)

• Self-Determination Theory (small groups)

• Millennial Learners (large group)

• Millennial Learners (small group)

• Report Back and Wrap Up

Motivational Interviewing

5 Key Principles of MI: Express Empathy

• Use reflective listening

– Use statements that demonstrate understanding of learner’s thoughts and feelings

– Accepting attitude

– Nonjudgmental

– Collaborative

• Reframing into potential change talk

– “It sounds to me like…”

5 Key Principles of MI:Develop Discrepancy

• Learner goals/values versus current behavior

Focus on discordance

Motivate change

• May achieve commitment to change

5 Key Principles of MI:Avoid Argument

• Avoid direct confrontation

• Arguments

– Counterproductive

– Leads to defensiveness

• Resistance change strategy

5 Key Principles of MI:Rolling With Resistance

• “Rolling” is not engaging or opposing

Reframing negative information

New, positive interpretation

• Perception can be shifted

5 Key Principles of MI:Support Self-Efficacy and Optimism

Precontemplation:

Not considering change, unwilling to change

Raise awareness Contemplation:

Aware but is ambivalent

Help to choose change

Determination:

Committed to change

Help identify change strategies

Action:

Taking steps toward change

Help implement change strategies

Maintenance:

Sustaining change

Develop new skills for maintaining

Recurrence/Relapse

Cope with consequences and determine next step

Stages of Change

Importance/Confidence/Readiness Ruler

• Probe lower

– Challenge patient to defend the positive

– Avoid probing upward early

• Probe upward later in the discussion

– “Which of the changes we discussed would need to occur to bring you up from 5 to 6?”

Spirit of Motivational Interviewing

• Collaboration (vs. Confrontation)

• Optimism

• Respect

• Evocation (Drawing Out vs Imposing Ideas)

• Autonomy (vs. Authority)

Using OARS

Open-ended Questions

Affirmations

Reflective Listening

Summary Statements

Using FRAMES

Feedback

Responsibility

Advice

Menu

Empathy

Self-Efficacy

Pair Share Activity

• Think about principles of MI

• Use OARS for Kelly’s heme/onc rotation

• Use FRAMES for Kelly’s current rotation

Self-Determination Theory

Self Determination Theory

• Framework of human motivation

• Prior: “Carrot and Stick”

• Developed by Edward Deci and Richard Ryan at the University of Rochester in the 1970’s

• Articulates intrinsic and extrinsic sources of motivation

• Yes, rewards can change our motivation – but for the better?

– Initial studies showed that students interested in an activity were transiently more engaged

when offered rewards, then less engaged from baseline when rewards removed

• Emphasized the quality, not the quantity of motivation

What Moves You?

• Extrinsic motivation: Doing something to

achieve a “separable outcome”

• Intrinsic motivation: “Doing an activity for its

inherent satisfactions rather than for some

separable consequences”

A Little More Theory

• SDT assumes humans are wired for intrinsic motivation

• Concerned with “the conditions which elicit and sustain, versus subdue

and diminish, this innate propensity”

– In the right setting, intrinsic motivation is natural

– Fairly easy to disrupt

Ryan RM, Deci EL. Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being. Am Psychol. 2000 Jan;55(1):68-78

Basic Psychological Needs

• Cognitive Evaluation Theory: Three basic psychological needs will foster

intrinsic motivation

– Autonomy

– Competence

– Relatedness

Ryan RM, Deci EL. Self-determination Theory Basic Psychological Needs in Motivation, Development, and Wellness. New York: Guilford, 2017.

Cognitive Behavioral TheoryBasic Psychological Needs

Optimal Health and Motivation

Competence

Relatedness

Autonomy

3 Basic Psychological Needs

Animated by Camp Stomping Ground, accessed 7/18/2017 at https://youtu.be/3sRBBNkSXpY. An excerpt from the opening keynote at The Self-Determination Theory Conference 2013 by Richard Ryan. Used with permission.

Regulatory Styles

• Organismic Integration Theory: Identifies three regulatory styles

– Amotivation

– Extrinsic motivation

– Intrinsic motivation

Ryan RM, Deci EL. Self-determination Theory Basic Psychological Needs in Motivation, Development, and Wellness. New York: Guilford, 2017.

Organismic Integration Theory

AmotivationExtrinsic

MotivationIntrinsic

Motivation

Impersonal

Apathy, Lack of

intention

External

Reward or Punishment

SomewhatExternal

Compulsion, guilt

SomewhatInternal

Thoughtful valuing of

goals

Internal

Assimilation of values into self

Internal

Pure interest, challenge, joy,

curiosity

How do we move our learners from A to Z…or I (Internalization and Integration)??Cook DA, Artino AR. Motivation to learn: an overview of contemporary theories. Medical Education. 2016;50(10):997-1014. doi:10.1111/medu.13074.Ryan RM, Deci EL. Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being. Am Psychol. 2000 Jan;55(1):68-78.

Self Determination Theory

AmotivationExtrinsic

MotivationIntrinsic

Motivation

ImpersonalApathy,

Lack of intention“CAN’T”

ExternalReward or

PunishmentPRIZE

IntrojectedCompulsion,

guilt“SHOULD”

IdentifiedThoughtful valuing of

goalsVALUE

IntegratedAssimilation

of values into self

“I AM”

InternalPure interest, challenge, joy,

curiosityJUST HAPPENS

RelatednessRespect, caring,

inclusivity, safety.

Competition, Criticism, Tradition

CompetenceChallenge, Positive

Feedback

Negative feedback, Impossible challenge

AutonomyChoice,

responsibility, acknowledging feelings, avoid

judgment

Rewards, imposed goals

See citation above

Why the Big Deal?

• Motivation matters to us!

• Quality of learning matters to us!

• Self-Determination Theory has been applied in multiple contexts –

all levels of education, business, parenting, health care. It works!

Getting to Intrinsic MotivationConditions that Facilitate Conditions that Undermine

Autonomy-Absence of Pressure-Goal Choice-Strategy Choice-Task Involvement-Promotion of Task Interest

Autonomy-Pressure toward Outcomes-Punishment Contingencies-Goal Imposition-Deadlines-Controlling Rewards-Ego-involvement-Surveillance

Competence-Optimal Challenge-Positive Feedback-Informational Rewards

Competence-Non-Optimal Challenges-Negative Feedback

Relatedness-Empathy-Warmth-Acknowledge Emotions

Relatedness- “Cold” Interactions- Lack of Positive Involvement

Ryan RM, Deci EL. Self-

determination Theory Basic

Psychological Needs in

Motivation, Development,

and Wellness. New York:

Guilford, 2017.

The Millennial Learner

How to motivate the unmotivated “star” of your show

Millennial learner (ML)• *Definition of ML: generation born between 1982 and

2002 (Howe & Strauss, 2000)

• Largest and most culturally diverse generational cohort

in U.S. history

• Preferences: collaborating, connecting, and creating

social change

• “tech savvy”

• “connecting and sharing information”*Pinder-Grover T, Groscurth, CR; PRINCIPLES FOR TEACHING THE MILLENNIAL GENERATION: INNOVATIVE PRACTICES OF U-M FACULTY, CRLT Occasional Paper No. 26, 2009

What the Literature Shows…

Strengths

Want to achieve

Team-oriented

Goal-oriented

Hard-working

Need transparency

Challenges

Anxious

Require frequent feedback

Learning needs to be personalized

Need sense of accomplishment

Need higher praise

Set expectations

Be a coach, not a teacher

Target learning on rounds

Focus on the patient

Build a community

A Framework

Millennials and Theory

Motivational Interviewing

-collaborative, nonjudgmental

-optimism through personalized learning

-evoke their perspectives

Self-Determination Theory

-Intrinsic motivation, comes from

within

-Autonomy, relatedness, competence

Your Turn

Thinking about your next time on service, what approaches can you take

to motivate millennial learners when motivation is at a winter low?

Millennial Theater:Small group break-out

• The Staging

• The Performance

• The Curtain Call

Report Back and Wrap Up

• Goals and Objectives

– Practice Motivational Interviewing skills to re-engage the unmotivated learner

– Apply Self-Determination Theory to the unmotivated learner and their

environment

– Examine tools and strategies known to engage Millennial learners

• Questions, Comments, What Worked for You?

References

• Bundy, C. Changing Behaviour: Using Motivational Interviewing Techniques. J R Soc Med. 2004; S44(97):43-47.

• Resnicow K, McMaster F. Motivational Interviewing: Moving from Why to How with Autonomy Support. Int J Behav Nutr Phys Act. 2012; 9:19.

• Miller WR, Rollnick S. (2013). Motivational Interviewing: Helping people change. New York, NY: Guilford Press.

• Chirkov V, Ryan RM, Kim Y, Kaplan U. Differentiating autonomy from individualism and independence: a self-determination theory perspective on internalization of cultural orientations and well-being. J Pers Soc Pscyhol. 2003 Jan;84(1):97-110.

• Miller, W. R., & Rollnick, S. (2002). Motivational Interviewing: Preparing people for change, (2nd ed.). New York, NY: Guilford Press.

• Sheldon L, Using Motivational Interviewing to Help your Students. The NEA Higher Education Journal, 2010, pp 153-159

References

• Lipman V. (2015, March 1) Study shows secret to managing millennials can be summed up in one word. Retrieved from:

https://clicktime.symantec.com/a/1/tvhzmUtjWk1rFuQDJADTvJR5GszrAFm4rLjkjIlu-

9Y=?d=_dq5jLpukx4E7x_jbavqP0Da8hbrYKFlTLSy_QIEWOfmaKPBfVR2JO4ykYart-UN89QV4ngrh5MLu3uWKJH6DtR9IwVvKOlrC9J-vTBJMR5JjCxJfQyfHQ-

ZSkPlyYkKT9EcxJf_3KbREtsjqteLYPwUByqgNOjrYAu2IfOR5cBCICQhY7H3uwPRPRL5x4KaPl5SyBKeuUM-

4Uj_7UwIsjUYFXpF9_s4hckiBHAArOrxNAieIEUTfiaY_Eto8Ng9VKD2Zv3uGnhctX3CsTvYAddZpstZ3ykjdwUJSiAtjkgoN4Prjr_eydTx1kMte1ZfobAgOSurdfCmj3h0

bvDIXQl59YGL1FMciK7dIEwn1zfG7mAJ9COiZpKACU8HHU-MnJ56EjY5aby-

AtrqtibWlW81e3tmPvzAXrzHSA%3D%3D&u=http%3A%2F%2Fonforb.es%2F1BOTJwW

• Benson T. (2016, February 11) Motivating millennials takes more than flexible work policies. Retrieved from:

https://clicktime.symantec.com/a/1/u2JRFEPJaXW03sA-AbA5feDaugBcJ2Y-

ekppDJLVobg=?d=_dq5jLpukx4E7x_jbavqP0Da8hbrYKFlTLSy_QIEWOfmaKPBfVR2JO4ykYart-UN89QV4ngrh5MLu3uWKJH6DtR9IwVvKOlrC9J-

vTBJMR5JjCxJfQyfHQ-ZSkPlyYkKT9EcxJf_3KbREtsjqteLYPwUByqgNOjrYAu2IfOR5cBCICQhY7H3uwPRPRL5x4KaPl5SyBKeuUM-

4Uj_7UwIsjUYFXpF9_s4hckiBHAArOrxNAieIEUTfiaY_Eto8Ng9VKD2Zv3uGnhctX3CsTvYAddZpstZ3ykjdwUJSiAtjkgoN4Prjr_eydTx1kMte1ZfobAgOSurdfCmj3h0

bvDIXQl59YGL1FMciK7dIEwn1zfG7mAJ9COiZpKACU8HHU-MnJ56EjY5aby-

AtrqtibWlW81e3tmPvzAXrzHSA%3D%3D&u=https%3A%2F%2Fhbr.org%2F2016%2F02%2Fmotivating-millennials-takes-more-than-flexible-work-policies

References

• Ryan RM, Deci EL. Self-determination Theory Basic Psychological Needs in Motivation, Development, and

Wellness. New York: Guilford, 2017.

• Ryan RM, Deci, EL. Self-regulation and the problem of human autonomy: does psychology need choice, self-

determination, and will? J Pers. 2006 Dec;74(6):1557-85.

• Cho KK, Marjadi B, Langendyk V, Hu W. Medical student changes in self-regulated learning during the transition

to the clinical environment. BMC Med Ed. 2017;17:59. doi:10.1186/s12909-017-0902-7.

• Ryan RM, Deci EL. Intrinsic and Extrinsic Motivations: Classic Definitions and New Directions. Contemp Educ

Pscyhol. 2000 Jan;25(1):54-67.

• Deci EL, Eghrari H, Patrick BC, Leone DR. Facilitating internalization: the self-determination theory perspective. J

Pers. 1994 Mar;62(1):119-42.

References

• Ryan, RM, Deci EL. Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being. Am Psychol. 2000 Jan;55(1):68-78.

• Richard Ryan - Facilitating children's motivation and wellness, talk given at University of Queenland, Australia.

• Martin, S. K., Farnan, J. M. and Arora, V. M. (2013), FUTURE: New strategies for hospitalists to overcome challenges in teaching on today's wards. J Hosp Med. 8: 409–413. doi:10.1002/jhm.2057

• Janeve R. Desy, Darcy A. Reed, Alexandra P. Wolanskyj, Milestones and Millennials: A Perfect Pairing—Competency-Based Medical Education and the Learning Preferences of Generation Y. Mayo Clin Proc. 2017;92(2):243-250. https://doi.org/10.1016/j.mayocp.2016.10.026.

• Toohey SL, Wray A, Wiechmann W, Lin M, Boysen-Osborn M. Ten Tips for Engaging the Millennial Learner and Moving an Emergency Medicine Residency Curriculum into the 21st Century. West J Emerg Med. 2016;17(3):337-343. doi:10.5811/westjem.2016.3.29863.

References

• Venne VL, Coleman D. Training the Millennial Learner Through Experiential Evolutionary Scaffolding:

Implications for Clinical Supervision in Graduate Education Programs. J Genet Couns. 2010;19(6):554-569.

doi:10.1007/s10897-010-9319-8.

• David H. Roberts, Lori R. Newman & Richard M. Schwartzstein (2012) Twelve tips for facilitating Millennials’

learning. Med Teach. 34:4,274-278, DOI:10.3109/0142159X.2011.613498

• Boysen PG 2nd, Daste L, Northern T. Multigenerational Challenges and the Future of Graduate Medical

Education. Ochsner J. 2016;16(1):101-107.

• DiLullo, C., McGee, P. and Kriebel, R. M. (2011), Demystifying the Millennial student: A reassessment in

measures of character and engagement in professional education. Anat Sci Ed. 4: 214–226. doi:10.1002/ase.240

• Pinder-Grover T, Groscurth CR. Principles for teaching the millennial generation: innovative practices of U-M

faculty. CRLT Occasional Papers. 2009; 26: 1-8.