Supervision Strategies to Enhance Implementation and Fidelity to EBP
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Transcript of Supervision Strategies to Enhance Implementation and Fidelity to EBP
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Supervision Strategies to Enhance Implementation and
Fidelity to EBP
Kelly Pitocco, LISW-S, LICDC
University of Cincinnati
Corrections Institute
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Putting Supervision in
Context of Implementation
Process
To Do . . . PractitionerTraining
State Policy
Funder
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Supervisor
Training and Support
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Supervisor
Training and Support
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The Four Phases of Learning
Preparation
Practice
Presentation
Performance
OftenSkipped
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Preparation
Assessing and Readying for Change
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Preparation
• Get them interested
• Encourage positive feelings about new learning
• Create Learning Environment
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Survey of AOD Professionals
83%
Past Year use ofCBTMETMI
12 Step Facilitation
75% Reported Currently Using EBPs
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However, Many have Negative View of Curriculum-based Treatment
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Attitudes About EBP
Most Clinicians eitherBelieve they are Using EBP
Or Want to Use EBP
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Positive Attitudes
• Using manual help counselor evaluate and improve skills
• Treatment manual will enhance outcomes
• Counselors are ethically obliged to use EBP
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Negative Attitudes
• EBP make staff more like technician than caring people
• Treatment manuals appropriate for research but not real life
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Readiness Factor
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Prepare for Implementation
• Determine if the organization and program are ready to adopt model
• Assess staff readiness to change
• Set up a multidisciplinary change committee
• Program leadership and change committee develop the training and follow-up plan
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Areas for Readiness
• Strategic Plan
• Readiness Assessment
• Project Management
• Change Management
• Staff Training
• Staff Supervision– Rating– Coaching
• Monitoring Fidelity– CQI– Evaluation
•Staff Training
•Staff Supervision•Rating•Coaching
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Goals for Preparation
• Get staff out of a passive or resistant mental state
• Remove learning barriers• Arouse interest• Give staff positive feelings about, and an
incentive to learn• Create active learners• Establish a learning group
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Techniques
• Provide positive suggestion
• Discuss benefits to clinician and client
• Set clear, meaningful goals
• Raise curiosity
• Create a safe and positive environment
• Calm staff fears
• Identify and remove barriers to learning
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Techniques
• Raising questions and posing problems
• Getting staff involved in implementation
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Learner Barriers
NO WIIFM
Need to Save Face
If it Ain’t Broken,Don’t Fix it
This is the WayWe’ve Always
Done it
The way I do itIs Good Enough
I don’thave Time
PersonalIssuesI already do this
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Learner Benefits
• Brainstorm benefits
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Curiosity Arousal
• Give people problems to solve in teams
• Send staff on fact-finding missions
• Play question and answer games
• Self-discovery activities
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Presentation
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Broader than Training
• Need a mechanism to accomplish:
– Acceptance of change
– Means to incorporate change
– Reinforced at all levels of system
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Typically underestimate the time and effort needed to:
• Train
• Implement
• Achieve fidelity to the model
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Occasional Quotes from Trainees
“I was told I have to be at this training.
I have no idea why I am here.”
“I’m just here to get my 30 hours/CE’s/
mandatories done”
“That won’twork at my
Site/with ourclients/withinthe time we
have.”
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Training Culture
Successful training experience wanes
with each disengaged participant
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Typical Reaction of Trainees
• Excited to learn a new clinical intervention
• Enthusiastic and committed to trying it with clients
• Although there wasn't much time for skill-building during the session, they have their notes and want to try it out
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Reality Returns
• Then they get back to the site– to the routine– to the caseload– to the demands by courts– to UR or required contacts– to the supervisor and co-workers who didn't
take the training– to the clients who aren't prepared for
something new or different
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Not Prepared
• Notes now seem incomplete
• Can’t recall details from the training
• Enthusiasm and new knowledge begin to fade
Adopting new
practices in the context
of everyday work is
difficult and frustrating
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Do One-Shot Trainings Work?
• 15 hour training on MI
• Pre-training baseline audiotape
• Helpful Responses Questionnaire
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Self-Report
• Participants over-inflated their skills of using MI after the training
• Use of MI declined with time following the training (about 50%)
• Skills were about ¼ of proficient
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Maximizing Gains from Classroom Training
• Use of knowledge-based pre/post tests
• Use of knowledge-based proficiency tests
• Use of skill-based rating upon completion of training
• Mechanism for use of data– Rated competent or continued development
until reach competent
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Role of Trainer
• Training is a means to an end – not an end in itself
• Trainer is Performance Consultant• Trainer partners with the learner• Link to business need• Proactive and reactive • Front end assessment and evaluation of
performance
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Evaluation
• Knowledge Test – pre/post
• Competency – skill-building sessions– Skill check off– Structure through policy and procedure– Program Integrity Evaluation– CQI or outcome evaluation
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Supervisory Strategies for Enhancing Training Transfer
• Communicate expectations prior to training
• Demonstrate involvement of training content – integrated (clinical and staff meetings, paperwork, etc)
• Hold learner accountable for applying content in work (rewards/sanctions)
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Supervisory Strategies for Enhancing Training Transfer
• Demonstrate and Model the skills
• Provide learning and practice opportunities
• Integrate learning objectives into performance appraisal
• Observe and provide feedback and coaching
• Booster training sessions
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What would the Supervisor need to be able to do those items?
Small Group Discussion
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Remember Two Part Process
Change Management
And
Skill Development
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Areas to Address
• Skill Deficit
• Resistance
• Both
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Role of Clinical Supervisor
• Safety
• Quality
• Effectiveness
• Compliance
Oh yeah, and . . . .Oversee servicesAdministrative TasksDaily Crisis ManagementPrepare ReportsManage CaseloadProvide coverageHire StaffAll other duties no one else wants to do
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Evidence Supporting Supervision
• Conditions– Manual Only– 14 hour Workshop– Workshop + Feedback– Workshop + Coaching– Workshop + Feedback + Coaching
All had initial Skill Acquisition
Miller, et. al., A Randomized Trial of Methodsto Help Clinicians Learn Motivational Interviewing.Journal of Consulting and Clinical Psychology (2004)
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Four Months Later
• Conditions– Manual Only– 14 hour Workshop– Workshop + Feedback– Workshop + Coaching– Workshop + Feedback + Coaching
Could not Detect Who had Training
Only condition that maintainedbenefit after 4 Months
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CBT Study• Conditions
– Manual Only
– Manual + Web-based Training (40 hours)
– Manual + Training + Supervision (observation and feedback)
Sholomskas, et. al., We don’t Train in Vain: ThreeStrategies of Training Clinicians in CBT .Journal of Consulting and Clinical Psychology (2005)
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CBT Study
• Conditions
– Manual Only – No Transfer
– Manual + Web-based Training (40 hours) - Modest Transfer
– Manual + Training + Supervision (observation and feedback) - Proficient
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Sholomskas, et. al., 2005
“Face to face training followed by supervision may be essential for effective technology transfer and raises questions about whether practitioners should feel competent to administer an empirically-
supported treatment on the basis of reading a manual alone.”
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Current State
• What is your current assessment of staff in providing evidence-based practices?
• What are the challenges in achieving staff proficiency?
• What changes could facilitate improvement in clinical supervision?
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Observed Contacts
• On a scale of 1 - 10
– How important is it for the clinical supervisor to have direct observation to effectively provide supervision?
– If you rated high – why?
– If you rated low – why not?
What do youthink your staff
would say?
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Behind Closed Doors
Ever Makeyou Nervous???
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Types of Interventions Used
Score of 4 Considered Proficient
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Types of InterventionsNever Used
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Types of InterventionsRarely Used
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What Were They Doing?
Those not Trained in Model
Significantly More “Chat”
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What was the Informal Conversation?
• Common Experiences
• Opinions not related to Treatment
• Current Events/News
• Personal Feelings about Client
• Work-Related Problems
• Professional Background
• Other
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Without Observation
• No chance to reinforce good work
• No correcting mistakes or inconsistencies
• No provision for gaps in skill
• No assurance of fidelity with model
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Practice
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Practice
• Integrate and incorporate the new knowledge or skill
• Use a variety of methods and scenarios
• Providing coaching and feedback
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Practice - Goals
• Integrate and incorporate new skill in direct practice situations
• Encourage transfer of skill to variety of situations
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Techniques
• Observations of current skill
• Together identify skill gaps
• Consider team or pair learning partnerships
• Contextual learning experiences
• Problem-solving exercises
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Techniques
• Develop activities for the staff to process learning
• Hands-on trial/feedback/reflection/retrial
• Real-world simulations
• Individual reflection and articulation
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Techniques
• Partner and team-based discussion• Collaborative teaching and review• Skill-building activities• Teachbacks• Interview staff member as if s/he was client• Best and worst critique• Tell a story that illustrates how skill was effective• Memory or job aids
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Strategies
• Role play• Trial and error• Microskills training • Written vignettes – if client says . . . you
respond _______.• Role play and make common mistakes –
have them identify mistakes and how to replace
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Strategies
• Clinician develops a pictogram or flow chart of the methods
• Imagery• Cards with vignettes – what would you
say? Or cards with skills – respond to the vignette
• Project client responses• Group brain role play
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Performance
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Performance
• Help apply and extend their new knowledge or skill to the job
• Create integrated skill
• Continuous improvement of performance
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Performance - Goals
• Make sure the learning sticks and is applied successfully
• Make sure the skill is applied in appropriate situations
• Continuous improvement
• Is the skill having the desired impact or outcome?
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Techniques
• Immediate real-world application• Creating and executing plan for clients• Follow-through reinforcement activities• On-going coaching• Performance evaluation and feedback• Peer support activities• Supportive organizational and environmental
changes
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Threats to Transfer of Learning
• No immediate need to apply the skill
• No support system for reinforcing the learning on the job
• A culture or work setting that is antithetical to the new learning
• No rewards for applying the skill
• No consequences for not applying the skill
• No time to integrate the new skill
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Early Attempts
• What worked well? What would have made it better?
• What were the problems with implementation and/or strategy
• How would you do it different?• What do you need to improve your
performance?
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Reinforcement Strategies
• Buddy System
• Rewards and Consequences– Evaluation system – objective measure– Self-evaluation– Review to see if the benefits are realized
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Current Measures
How do we determine performance?
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Specific Measures - Examples
• Uses EBP language during interactions
• Goals address criminogenic needs
• Avoids power struggles with clients
• Consistently applies protocol for rewards and sanctions
• Helps client identify thinking errors and correctives in neutral manner
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Fidelity
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Fidelity
Implementing the intervention as closely as possible to the way it was designed and
delivered during the research stage
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Drift
• Accidental adaptation can pose significant problems
• Too much adaptation might decrease an intervention's effectiveness
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Evaluation
• Effective programs utilize Continuous Quality Improvement
• Assess clinical targets and outcome data
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The Role of QA/QI in Community Corrections (based on UC Halfway House and CBCF study)
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Every major study shows strong relationship between program
integrity and recidivism
INTEGRITY
RECIDIVISM
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Program Integrity and Treatment Effect in Residential Programs
As Scores for Integrity RiseProgram Lowers Recidivism
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Therapist Competency Ratings and Recidivism
Having Unskilled CliniciansWorst than Providing No Treatment
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Rating Systems
Individual adherence to EBP
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Fidelity to Model
Not a discussion of
RIGHT or WRONG
Identifying what is
CONSISTENT OR INCONSISTENT
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Process of Supervision
(1) Direct observation of treatment sessions
(2) Structured feedback about adherence and competence
(3) Coaching to improve implementation with proficiency
(4) Evaluate
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Training and Supervision Model
• Intensive training by expert for clinicians and supervisors
• Program-based supervisors proficient – based on rating
• Staff turn in tapes or observed with feedback and coaching
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Training and Supervision Model
• Continued intensive supervision until achieve proficiency rating in 3 sessions
• Ongoing individual or group supervision
• Consultant monthly contact with supervisors
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Anxiety with Rating
• Emphasis on learning process – don’t tie to evaluation until a preplanned learning curve period
• Emphasis on improving rather than criticism
• Utilize model in feedback
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Rating Process - Example
Motivational Interviewing – MIA:STEP
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Rating Items
MI Consistent Items• MI Style• Open Ended ?’s• Affirmations• Reflections• Foster Collaboration• Motivation Change• Discrepancies• Pros/Cons• Change Planning• Client-Centered FB
MI Inconsistent Items• Unsolicited Advice• Emphasize Abstinence• Direct Confrontation• Powerlessness• Asserting Authority• Closed-Ended Questions
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Adherence
• Indicate when the person demonstrated the Skill
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Competence
• Higher Quality – 4 through 7
• Lower Quality – 1 through 3
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Agreement About Occurrence
• Supervisor and Clinician rated similarly with Clinician rating higher
• Independent rater rated lower in most cases
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Feedback
• Specificity about performance strengths and weaknesses
• Routine and formal discussions
• Opportunities for counselor self-evaluation and input
• Help counselor develop discrepancy between current interventions and goal
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Coaching Format
• Start with strengths• Show them the rating sheet• Listen to tape or give specific examples• Ask clinician for area they would like
coaching • Suggest role play• Summarize• Plan for next time
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Development
• Establish Standards and Expectations
• Monitor Clinical Services Regularly
• Provide Feedback
• Collaborate on Professional Development Plans
• Facilitate Knowledge and Skill Acquisition
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Reduce Burnout
CLINICAL SUPERVISION
EXHAUSTIONAND
TURNOVER
NIDA study reveals that clinical
supervision was negatively
associated with emotional
exhaustion and turnover
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Creating Lesson Plans
• Identify a skill-based learning goal for each supervisee
• Develop a learning plan– Preparation– Presentation– Practice– Performance
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Summary and Review
• Design with the Learning Cycle– What are the four P’s?
• Appeal to the Learning Style of your learner– How can you be SAVI?
• Get the learner involved• Create a Learning Environment and Community• 30/70 Rule
30% preparation and presentation70% practice and performance
• Be flexible to the needs of the learner
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Closure
Be the change you want to see in the world
Ghandi