Steve Wiland, LMSW, ICADC - DWMHA Pasquale Vignola, MA, LLP - VCE Sheila Blair, AA – VCE

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

Uses multiple skills simultaneouslyAdopts a multifactorial understanding

ApplicationSkills and understanding are applied to a

consumer situationApplication 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


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


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)


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)


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)


Common Responses Most common response is to provide

trainingProvider 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

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

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


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


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 skillsSource: Eastern Michigan

University

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”)


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


Types of Supervision

Clinical

Administrative

Supportive

Competence-based


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.


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


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.


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


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)


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


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


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


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


Managing Expertise• Administration• Organization• Some practices

• Some practices (especially EBPs)

• Specialized practices

• Self-capacities• Case load

• Overlapping training

• Some practices

Supervisor is Expert

Neither is Expert

Supervisee is Expert

Both are 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


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


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


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


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


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


Building Competence


Structuring for Competence Pick your trainers well

Avoid one-time eventsEnsure 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


Integrating Training & Practice Training should reflect work

Focus training opportunities (in-house?)Build training applications into supervision

agendasPair supervisors and workers in training

plans Infuse training content into agency

patterns Integrate training/teachable moments into

group supervision or team meetingsStructure innovation discussions into

meeting schedulesSource: Eastern Michigan University

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

Social Worker 41.9% Administrative 29.0% Case Manager 10.2% Direct Care/CMH 8.8% Professional Counselor 8.6% Psychologist 6.3%


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%


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

2001 Report “Crossing the Quality Chasm”

2005 Report “Improving the Quality of Health Care for Mental and Substance-Use Conditions”

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

Benefits of Online Knowledge-Based Learning:Opportunity for disseminating up-to-date

information without travel costsCan be completed at work, home or

anywhere with Internet accessWork at own paceCan include skill elements, with the use of

videos and interactive exercises


Distance Learning:

Types offered: Live video conferencing capability with

five established sites and portable equipment to expand to 20 live sites

Synchronous web-streamingAsynchronous 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: 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: 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): 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:

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:

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-DeterminationMichigan Public Health Institute (MPHI)

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 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.

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.

http://peds.stanford.edu/faculty-resources/documents/JAMA_resident_prep_2001.pdf

http://peds.stanford.edu/faculty-resources/documents/JAMA_resident_prep_2001.pdf

http://www.josiahmacyfoundation.org/

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.

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.

Shahmoon Shanok, 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.

Documents

Steve Wiland, LMSW, ICADC - DWMHA Pasquale Vignola, MA, LLP - VCE Sheila Blair, AA – VCE