Dissemination of motivational interviewing : the role of workshop training and subsequent supervision in the development of competence in clinical practice

Sammanfattning: Aim: Training practitioners is often used as the primary implementation strategy to disseminate evidence based practices into clinical and community settings. The overall objective of this thesis was to evaluate various aspects of training practitioners as part of the dissemination and implementation of motivational interviewing (MI). Method: In Study I, ten supervisors from a randomized controlled trial responded to semi-structured interviews about their supervision behaviors. Study II and III were conducted with practitioners in five Swedish county councils: In Study II, 174 practitioners were randomized to: 1) Regular county council workshop training; or 2) Regular county council workshop training followed by telephone supervision sessions based on objective feedback. All participants recorded three to eight sessions with actors. In Study III, the 98 participants from Study II receiving supervision were randomized to objective feedback based on either: 1) Half of a feedback protocol; or 2) The entire protocol. In study IV, 134 employees from The Swedish National Board of Institutional Care (SiS) with at least one completed MI training course were randomized to: 1) Six months of regular SiS supervision; or 2) Six monthly sessions of telephone supervision based on objective feedback. Study IV also replicated Study III. All participants in Study IV recorded three to seven sessions with a client or a colleague. Results: While many of the reported supervisory behaviors in Study I were similar, there where also variations. Moreover, none of the supervisors described the feedback protocol as relatively important for the supervisees to learn MI, and half of them expressed concerns regarding an eventual negative impact of the objective feedback. In Study II, the different county councils workshops trainings increased the participants’ MI skills to virtually the same level, and the subsequent supervision group showed larger proficiency gains at follow-up. In Study III, the group receiving feedback based on half of the protocol performed better at only two of the seven skill measures, and the objective feedback did not negatively affect the supervisory relationship or provoke supervisee discomfort/distress. In study III, many participants met the benchmarks for beginning proficiency already at baseline, and the regular group supervision and the supervision based on objective feedback were equally effective. The group that received feedback on half of the protocol performed better on only one of the seven skill measures, and the feedback did not negatively affect the supervisory relationship or provoke supervisee discomfort/distress. Conclusions: In accordance with previous research, both Study II and IV showed that workshop training can increase participants’ MI skills, and that subsequent supervision can further enhance acquired skills. Additionally, both studies indicate that these results also apply to naturalistic settings. However, the high variations in competence at all assessment points, together with the low interest in the possibility of subsequent supervision in both studies, are troublesome. In addition, neither the workshop trainings, nor the costly additional sessions of individual telephone supervision, or the comprehensive MI-implementation within SIS, were sufficient for many of the participants to reach beginning proficiency levels. This raises questions regarding both the most efficient form of training for practitioners to attain and sustain adequate practice standards, and how to create an interest among practitioners to participate in such training. Moreover, the results from Study III and IV showed that objective feedback does not seem to provoke significant supervisee anxiety or negatively affect the supervisory relationship. Although restricting the number of variables when providing objective feedback might promote learning during supervision, the observed differences in skill acquisition in both these studies were small, and it is not clear what really generated them. Since objective feedback seem to be an important part of supervision, and efficient supervision an important factor for the dissemination and implementation of evidence based practices, constructive replications are needed to ascertain the mode and complexity of feedback that optimizes practitioners’ learning.