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Overcoming Barriers to Provide and Sustain Evidence-Based, Best and Promising Practices Through Technology-Supported Workforce Development. Steve Wiland , LMSW, ICADC - DWMHA Pasquale Vignola, MA, LLP - VCE Sheila Blair, AA – VCE . The Challenge of Competence. Complexity

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Overcoming Barriers to Provide and Sustain Evidence-Based, Best and Promising Practices Through Technology-Supported Workforce Development

Steve Wiland, LMSW, ICADC - DWMHA

Pasquale Vignola, MA, LLP - VCE

Sheila Blair, AA – VCE

the challenge of competence
The Challenge of Competence
  • Complexity
    • Uses multiple skills simultaneously
    • Adopts a multifactorial understanding
  • Application
    • Skills and understanding are applied to a consumer situation
    • Application retains a sense of goal achievement and consumer need
  • Action
    • Practitioners must adopt an active response to create movement or resolution

Source: Eastern Michigan University

dimensions of competence
Dimensions of Competence

Source: Eastern Michigan University

the problem with graduates
The Problem with Graduates
  • Policy makers insist on EBPs but practitioners do not have requisite competencies (Sburlati et al., 2011)
  • Graduates from all types of university programs do not possess the necessary competencies for effective CMH practice (Biesma et al., 2010; Heiwe et al., 2005; Nelson & Graves, 2011; O’Donovan et al., 2005)
  • Graduate shortcomings are particularly acute in the areas of Evidence-Based Practices (Manuel et al., 2009; Sigel & Silovsky, 2011

Source: Eastern Michigan University

the disconnect
The Disconnect
  • There is a disconnect between the teaching in universities and the needs of community mental health (Biesma et al., 2008; Rugs et al., 2011)
  • University programs do not prioritize EBPs even though these are priority competencies in community mental health (Blumenthal et al., 2001; Hoge et al., 2002)
  • University programs are often reticent to change curriculum in response to shortcomings identified in the field (Akister, 2011)

Source: Eastern Michigan University

university realities
University Realities
  • University systems undervalue teaching students in favor of research and external funding (Hoge et al., 2002)
  • Universities tend to use knowledge transfer approaches to teaching rather than expecting students to demonstrate competencies (Crits-Cristoph et al., 1995; Nelson, 2001; Wilson & Kelly, 2010)
  • Universities rely on internship experiences for competence development but these experiences are not uniform or consistent (Heiwe et al., 2011; Lehman et al., 2011)

Source: Eastern Michigan University

the cmh realities
The CMH Realities
  • When graduates enter CMH agencies
    • CMH settings are under-resourced and overburdened making it hard to compensate for educational shortfalls (Heiwe et al., 2011; Lehman et al., 2011)
    • CMH providers may expect practitioners to have pre-requisite competencies for practice
    • New graduates tend to abandon school-based learning and rely on nearby colleagues (Lombardozzi & Casey, 2008)

Source: Eastern Michigan University

common responses
Common Responses
  • Most common response is to provide training
    • Provider systems hire trainers to help the workforce achieve basic competence levels
    • MDCH provides training to support the statewide workforce in providing effective interventions
    • Professional organizations mandate practitioners to continue development
    • University partnerships or technology transfer centers are used to support integration of EBPs

Source: Eastern Michigan University

knowledge based training
Knowledge-Based Training
  • Lectures
  • Self-study: Journal articles and books
  • Auditing classes
  • Conversation with colleagues and experts
  • Attendance at interactive training events

(NOTE: all strategies transfer knowledge from the perceived expert to the practitioner)

Source: Eastern Michigan University

online knowledge based learning
Online Knowledge-Based Learning
  • Relatively new format
  • Opportunity for disseminating up-to-date information without travel costs
  • Can be completed at work, home or anywhere with internet access
  • Work at own pace
  • With videos and interactive exercises can also develop skill elements

Source: Eastern Michigan University

attitude based training
Attitude-Based Training
  • Training events with videos and activities to challenge thinking
  • Experiential training events using emotional power to create dissonance between status quo and ideal situations
  • Typically learning strategies involve experience followed by group discussion

Source: Eastern Michigan University

pseudo skills based training
Pseudo-Skills-Based Training
  • Includes provision of knowledge coupled with modeling and/or opportunities to practice skill elements
  • Modeling may involve use of video or live demonstrations of skills with discussion
  • Often involves breaking into groups, applying skill elements and then reporting back
  • Motivates participants to continue practicing the involved skills

Source: Eastern Michigan University

problems with training
Problems with Training
  • Training is best for advancing knowledge and attitudes, but typically unsuccessful at developing competence
  • There is an immediate drop-off in motivation and application within days
  • Competence development is a longer process requiring frequent input and support
  • While some training protocols with EBPs have such protocols, most training fails to extend input or support (aka “coaching”)

Source: Eastern Michigan University

supervision to develop competencies
Supervision to Develop Competencies
  • There is often an expectation that front-line supervisors promote competence
  • Supervisors believed to be assisting practitioners in developing knowledge and skills for effective practice
  • Supervisors are positioned to be the guarantor or to provide the organizational protection against sub-standard practice

Source: Eastern Michigan University

types of supervision
Types of Supervision
  • Clinical
  • Administrative
  • Supportive
  • Competence-based

Source: Eastern Michigan University

clinical supervision
Clinical Supervision
  • Support and teaching to develop practitioner knowledge and competence.
  • Enables the practitioner to assume responsibility for their own practice.
  • Enhances consumer protection and the safety of care in complex clinical situations.

Source: Eastern Michigan University

administrative s upervision
Administrative Supervision
  • Ensures that
    • work is performed,
    • paperwork is complied with,
    • billing and administrative procedures occur
  • Administrative supervision is crucial to agency functioning
  • In a busy environment, administrative functions can exert high demands on supervisors as the priority focus

Source: Eastern Michigan University

supportive supervision
Supportive Supervision
  • Operates concurrent with clinical and administrative supervision
    • Individualized support
    • Decreases burnout
    • More mutuality in the relationship
  • It can be provided whenever the practitioner needs support, on an as-needed basis.

Source: Eastern Michigan University

competence based supervision
Competence-Based Supervision
  • Observes the practitioner’s skill performance
  • Evaluates the performance based on accepted standards
  • Provides immediate feedback on the skill performance
  • Explores skill adjustments for subsequent improved applications

Source: Eastern Michigan University

ideal elements for all types
Ideal Elements for All Types
  • Safe environment in which a supervisee can discuss thoughts and feelings
  • Trusting relationship modeling the openness of the helping alliance with consumers
  • Regular time frames with clear and respected expectations
  • Reflective feedback to think meaningfully about one’s work, one’s self

(Shahoom-Shanok, Gilkerson, Eggbeer & Fenichel, 1995)

Source: Eastern Michigan University

supervisory prerequisites
Supervisory Prerequisites
  • Pre-existing competencies to develop feedback
  • Ability to describe observations to avoid defensive reactions
  • An exploratory approach for developing alternatives with the supervisee
  • Development of reflective exchanges with supervisee

Source: Eastern Michigan University

prerequisites continued
Prerequisites Continued…
  • Ability to contribute new knowledge to the practitioner
  • Ability to motivate, and understand practitioner motivational needs
  • Ability to apply discussions back to practitioner situations
  • Ability to establish next steps and implementation plans

Source: Eastern Michigan University

time challenges in cmh
Time Challenges in CMH
  • Ideal supervision requires time and mutual investment
  • Job demands can interfere with optimal supervision
  • Interference is likely to diminish the importance of developmental input
  • Developmental work shifts input to colleagues, which may represent less-than-optimal feedback

Source: Eastern Michigan University

expertise challenges with ebps
Expertise Challenges with EBPs
  • Supervisor may not have the requisite information and skills for competence-development (credentialing issues)
  • Administrative and support functions are demanding
  • Often the EBP-related input is minimized, rendering it less important
  • Competence development suffers because of competing demands on supervisor and supervisee

Source: Eastern Michigan University

managing expertise
Managing Expertise

Source: Eastern Michigan University

when supervisor is expert
When Supervisor is Expert
  • Uses expert knowledge to provide feedback and input
  • Relationship ideally identifies the supervisory expertise
  • Roles are clear regarding learner and teacher during supervision

Source: Eastern Michigan University

when supervisee is expert
When Supervisee is Expert
  • Supervisor adopts administrative and supportive roles
  • Clinical supervision can be provided in general areas
  • Supervisee operates autonomously within the area of clinical expertise
  • Supervisee may operate as a mentor to other staff – elevates profile on the team
  • Administrative and legal requirements remain with the supervisor

Source: Eastern Michigan University

when both are expert
When Both are Expert
  • When topics of mutual expertise emerge exchange is collegial rather than hierarchical
  • Often different approaches lead to divergent thinking on consumer situations
  • Must have an agreement about how to handle differences
  • Requires high levels of maturity to manage the relationship

Source: Eastern Michigan University

when neither are expert
When Neither are Expert
  • Consumer situations result in guessing and trial-and-error responses
  • Past practice becomes normative and habitual responses dominate
  • Expertise must come from outside the team or agency
  • Requires resources and advocacy to prioritize the expenditure

Source: Eastern Michigan University

managing challenges without compromise
Managing Challenges Without Compromise
  • To ensure workforce competence, development-related input is needed
  • It is unrealistic to believe that a supervisor can manage all elements
  • It is equally unrealistic to believe that training by itself will improve workforce development
  • Important shifts are needed in the work environment

Source: Eastern Michigan University

the importance of repeated feedback
The Importance of Repeated Feedback
  • Competence requires applied action followed by immediate feedback
  • Feedback should be customized for each person to meet their developmental needs
  • Application and feedback should repeat multiple times with adjustment during each cycle

Source: Eastern Michigan University

building competence
Building Competence

Source: Eastern Michigan University

structuring for competence
Structuring for Competence
  • Pick your trainers well
    • Avoid one-time events
    • Ensure application, observation and feedback
  • Level Specific Training Plans
    • Have plans for each level in the organization
    • Dovetail the plans to reinforce each other
  • Scaffold your training plan
    • Develop training benchmarks and milestones
    • Use benchmarking to integrate training
    • Identify activities between events to reinforce competence

Source: Eastern Michigan University

integrating training practice
Integrating Training & Practice
  • Training should reflect work
    • Focus training opportunities (in-house?)
    • Build training applications into supervision agendas
    • Pair supervisors and workers in training plans
  • Infuse training content into agency patterns
    • Integrate training/teachable moments into group supervision or team meetings
    • Structure innovation discussions into meeting schedules

Source: Eastern Michigan University

workforce training survey
Workforce Training Survey
  • Survey of trainings selected by staff
  • Conducted in 2011
  • 1000 surveys returned in the first month
  • Average age = 46 years
  • Average years in the field = 14.16

Source: VCE Workforce Development Survey, 2011

most common job categories
Most Common Job Categories
  • Social Worker 41.9%
  • Administrative 29.0%
  • Case Manager 10.2%
  • Direct Care/CMH 8.8%
  • Professional Counselor 8.6%
  • Psychologist 6.3%

Source: VCE Workforce Development Survey, 2011

license type
License Type
  • Social Work (MSW) 50.8%
  • Social Work (BSW) 17.6%
  • Licensed Professional Counselor 13.0%
  • Psychology 12.2%
  • Certified Addictions Counselor 11.3%
  • Nursing 4.5%

Source: VCE Workforce Development Survey, 2011

types of trainings taken
Types of Trainings Taken
  • Recipient Rights (online/required) 79.1%
  • HIPAA (online/required) 75.3%
  • Person-Centered Planning (online/required) 64.2%
  • Medicaid Hearings etc (online/required) 59.0%
  • Ethics/Pain Management (SW licensing) 41.5%
  • Children’s Mental Health Grand Rounds 41.3%
  • Special Topics (online) 41.0%
  • Suicide Prevention Trainings 33.1%
  • Trauma Learning Series 27.7%

(NOTE – most focus in on required trainings or easy access)

Source: VCE Workforce Development Survey, 2011

institute for medicine recommendations
Institute for Medicine Recommendations
  • 2001 Report “Crossing the Quality Chasm”
  • 2005 Report “Improving the Quality of Health Care for Mental and Substance-Use Conditions”
challenges in training
Challenges in Training:
  • State requires specific Social Work credits, not NASW
  • Trainings are rarely relevant or provide new information
  • Work schedule and budget will not allow much training time or fees
  • Hard to keep track of credits when earned
ensuring a competent workforce from training to practice
Ensuring a Competent Workforce: From Training to Practice
  • Benefits of Online Knowledge-Based Learning:
    • Opportunity for disseminating up-to-date information without travel costs
    • Can be completed at work, home or anywhere with Internet access
    • Work at own pace
    • Can include skill elements, with the use of videos and interactive exercises

Source: Eastern Michigan University

distance learning
Distance Learning:
  • Types offered:
    • Live video conferencing capability with five established sites and portable equipment to expand to 20 live sites
    • Synchronous web-streaming
    • Asynchronous learning (credit and non-credit)
  • Popular distance learning websites:
    • College of Direct Support (Elsevier)
    • Improving MI Practices
    • Relias (formerly E-Learning)
    • Virtual Center of Excellence (VCE)
cost benefit analysis
Cost Benefit Analysis:
  • Conducted by Plante Moran in 2011
  • Discoveries:
    • In 2011, VCE’s online training offerings saved Detroit Wayne Mental Health Workforce $1.6 MILLION in travel time and mileage; an additional amount saved that was not in this calculation was revenue lost when employees were unable to see clients because they were at a training
    • Cost per credit decreases over time as more people take trainings

Source: Plante Moran

benefits of combining live and online training
Benefits of Combining Live and Online Training:
  • Social Workers can only obtain 10 hours of their 45 licensure hours online
  • Some learners prefer a live format
  • Some training formats that are very audience interactive do not translate well into online trainings
  • VCE obtains Social Work credits for nearly all of its live trainings
  • VCE offers some live events in six or more locations at once for the convenience of participants
continuing education credits cecs
Continuing Education Credits (CECs):
  • VCE is an approved provider of CECs for licensed social workers (through MI-CEC), licensed professional counselors (through NBCC) and certified alcohol and drug counselors (through MCBAP.
  • Partner with WSU School of Medicine for CME
  • Partner with Hospice of Michigan for CNE
  • Other credits available through VCE:
    • CRC
    • MCOLES
    • AFC
fiscal year 2012 2013
Fiscal Year 2012/2013:
  • 61,700 individuals participated in VCE’s live and online trainings
  • 75,628 Social Work Continuing Education Credits were earned
  • 73,472.5 Counseling Credits were earned
  • 44,848.5 CMHP Credits were earned
  • 17,501.5 Medical Staff Education Credits were earned
  • 18,891 Substance Use Education Credits were earned
feedback loop expertise
Feedback Loop & Expertise:
  • Work with Universities
  • Workforce Development Committees
  • Workforce Surveys & Event Evaluations
  • Establish curricula with non-university organizations such as:
    • Michigan Association for Infant Mental Health (MI-AIMH)
    • The Center for Self-Determination
    • Michigan Public Health Institute (MPHI)
learning organizations such as elsevier improving michigan practices relias and vce
Learning Organizations Such as Elsevier, Improving Michigan Practices, Relias, and VCE
  • Live and Online:
    • Annual required trainings by MDCH for CMH employees
    • Employer-required trainings, eliminating the need to do so much in-house and new-hire training
    • Evidence-Based Practices
    • Licensure-required trainings
    • Discipline-based required training (TBI, Self-Determination, etc.)
    • Child Mental Health Professional Trainings (get all 24 of your annual credits online)
    • School-based trainings (subjects on bullying, autism, suicide prevention, etc.)
references
References
  • Akister, J. (2011). Protecting children: The central role of knowledge. Practice: Social Work in Action, 23(5), 311-323.
  • Becan, J., Knight, D., & Flynn, P. (2012). Innovation adoption as facilitated by a change-oriented workplace. Journal of Substance Abuse Treatment, 42(2), 179-190. doi:10.1016/j.jsat.2011.10.014
  • Biesma, R.G., et al. (2007). Using conjoint analysis to estimate employers’ preferences for key competencies of master level Dutch graduates entering the public health field. Economics of Education Review, 26(3), 375-386.
  • Biesma, R.G., et al. (2008).Generic versus specific competencies of entry-level public health graduates: Employers’ perceptions in Poland, the UK, and the Netherlands. Advances in Health Sciences Education, 13(3), 325-343.
references1
References
  • Blumenthal, D., Gokhale, M., & Campbell, E.G. (2001). Preparedness for clinical practice: Reports of graduating residents at academic health centers. Journal of the American Medical Association, 286(9), 1027-1034. Retrieved from: http://peds.stanford.edu/faculty-resources/documents/JAMA_resident_prep_2001.pdf
  • Committee on Crossing the Quality Chasm: Adaptation to Mental Health and Addictive Disorders Board on Health Care Services. (2006). Increasing workforce capacity for quality improvement (Chapter 7). Improving the Quality of Health Care for Mental and Substance-Use Conditions: Quality Chasm Series. Washington, D.C.: Institute of Medicine of the National Academies – The National Academies Press.
  • Crits-Cristoph, P., Chambless, D.L., Frank, E., Brody, C., & Karp, J.F. (1995). Training in empirically validated treatments: What are clinical psychology students learning? Professional Psychology: Research and Practice, 26, 514-522.
  • Hager, M., Russell, S., Fletcher, S.W., (eds.). (2007). Continuing Education in the Health Professions: Improving Healthcare Through Lifelong Learning, Proceedings of a Conference Sponsored by the Josiah Macy, Jr. Foundation; 2007 Nov 28 - Dec 1; Bermuda. New York: Josiah Macy, Jr. Foundation; 2008. Accessible at www.josiahmacyfoundation.org.
references2
references
  • Heiwe, S., et al. (2011). Evidence based practice: Attitudes, knowledge and behavior among allied health care professionals. International Journal for Quality in Health Care; 23(2), 198-209.
  • Hoge, M.A., Jacobs, S., Belitsky, R., & Migdole, S. (2002). Graduate education and training for contemporary behavioral health practice. Administration & Policy in Mental Health, 29(4-5), 335-357.
  • Lombardozzi, C. & Casey, A. (2008). The impact of developmental relationships on the learning of practice competence for new graduates. Journal of Workplace Learning, 20(5), 122-143.
  • Nelson, T.S. & Graves, T. (2011). Core competencies in advanced training: What supervisors say about graduate training. Journal of Marital & Family Therapy, 37(4), 429-451.
references3
references
  • Rugs, D., Hills, H.A., Moore, K.A., Peters, R.H. A community planning process for the implementation of evidence-based practice. Evaluation & Program Planning, 34(1), 29-36.
  • Sburlati, et al. (2011). A model of therapist competencies for the empirically supported cognitive behavioral treatment of child and adolescent anxiety and depressive disorders. Clinical Child & Family Psychology Review. DOI 10.1007/s10567-011-0083-6.
  • ShahmoonShanok, R., Gilkerson, L., Eggbeer, & Fenichel, E. (1995). Reflective supervision: A relationship for learning. Washington, D.C.: Zero to Three, 37-41.
  • Sigel, B.A. & Silovsky, J. (2011). Psychology graduate school training on interventions for child maltreatment. Psychological Trauma Theory, Research, Practice, and Policy, 3(3), 229-234.
  • Simpson, D. D. (2009). Organizational readiness for stage-based dynamics of innovation implementation. Research on Social Work Practice, 19(5), 541-551.
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