The use of evidenced-based behavioral interventions in medical settings can lead to reduced medical service utilization, thus offsetting the cost of providing the intervention. Given the variability and complexity of medical settings, implementing evidence-based practices (EBPs) can be challenging. There is a strong evidence base indicating that for providers, true skill acquisition and maintaining fidelity to a practice requires ongoing supervisory monitoring and performance feedback in addition to initial training. At the Health Behavior Research and Training Institute we offer a variety of training and coaching methods, which allows us to tailor the training to the specific needs of the provider. Here we describe our training components and provide some of our training projects.
The HBRT Initial Two-day Training Workshops are led by experts in the evidence-based practice. Our expert trainers are all members of the Motivational Interviewing Network of Trainers (MINT). Each workshop is led by two trainers to maximize the amount of personalized feedback provided to the trainees. Day One includes six hours of didactics, practice exercises, demonstrations, role plays, and videos designed to teach the EBP and or specific protocol. Day Two incorporates actual case examples provided by the trainees in role plays for the purpose of further refining skills and techniques. Additional video demonstrations and practice using the Video Assessment of Simulated Encounters is used when training in Motivational Interviewing (MI).
At HBRT we offer an intensive coaching model that follows the completion of the initial 2-day workshop. Each trainee is assigned a coach and provided with a digital recorder so actual sessions can be recorded and uploaded to the HBRT secure website. The coaching process is designed to be highly collaborative, positive, and supportive in nature. Coaches are experts in MI and other EBP’s including Project CHOICES. Coaches generally review 1-2 recorded sessions a month. The expert Coaches will code the recordings using a session protocol checklist and for MI, the Motivational Interviewing Treatment Integrity (MITI) Coding System. The MITI assesses clinician competence in MI by counting specific behaviors such as simple and complex reflections, open and closed questions, MI-Adherent statements (i.e., ask permission, affirm, emphasize autonomy, support) and MI-non-Adherent statements (i.e., give advice, confront, direct), as well as global ratings of empathy, direction, and MI spirit (autonomy/support, evocation, collaboration). In terms of behavior counts, the MITI codes are mutually exclusive, such that each clinician utterance is given only one code, while the global ratings describe the overall impression of the session.
Standardized Patient Training: Modeled after the Objective Structured Clinical Examination (OSCE)
Another unique component of the HBRT-EBP training is the development and implementation of a standardized patient training program modeled after the OSCE format and tailored to the Particular EBP and trainee population. In medical education, OSCE or standardized patient (SP) trainings are used to help medical students learn how to communicate effectively with patients before being required to work with actual patients. Residents in training also receive instruction using standardized patients well into their medical careers to address difficult problems or challenges such as substance abuse and behavior change counseling. In the OSCE trainings, SPs are trained actors who portray patients who discuss specific symptoms while being interviewed by medical students, residents. On a typical day of SP training, the student or resident participates in a series of interactions with different SPs in various medical scenarios which are observed live on video monitors by instructors who enter the training room and provide immediate feedback to the trainees after each interaction session. Studies using SPs have found improvement in trainees’ skills in substance abuse and behavior change counseling.
In the HBRT trainings, SP actors have been trained to depict patients who drink at risk levels or abuse other drugs in case scenarios involving issues that the trainees would often encounter. In addition, the SP cases are designed to represent typical patients in medical settings in which the clinician or other medical provider would approach them and ask for permission to discuss their alcohol, drug, and tobacco screening results. Cases generally include patients in different stages of readiness for change, such as those less ready (i.e., in precontemplation or contemplation) or those more ready (i.e., in preparation or action). The trainees will typically move through 4 to 6 mock sessions that are video-taped and observed on a video monitor by an expert coach whose real time observations, protocol checklists and MITI codes are used to provide feedback immediately after each interaction. This sequenced process allows the trainee to incorporate feedback and apply it in the subsequent mock sessions.
SP training ideally occurs 2-3 months after an initial training. This process allows trainees to practice what they have learned in the initial training, obtain experience and receive feedback while actively working in the field. Following the SP practice and training, Specialists can continue to receive monthly individualized coaching.
Ongoing Monitoring of Competency
Monthly consultation calls are also provided by HBRT expert coaches as well as ongoing consultation as needed.