Improving Practice in Community-based Settings: A Randomized Trial of Supervision

描述（由申请人提供）：本R01提案的主要目标是研究社区环境中不同监管策略对临床医生忠诚度和客户结果的影响。先前的研究已经确定，不包括一段时间的针对具体干预的监督或咨询的培训方法是无效的，而只包括最初一段时间的监督的实施努力最终会在实践中显示出知识和忠诚的衰减。在社区环境中有效和持续地实施循证实践（ebp）可能需要持续的监督。然而，监督是培训中调查最少的方面之一。来自疗效试验的“金标准”监督要素包括对治疗过程的审查、监测来访者结果和模型保真度的标准化程序，以及持续的技能培养（例如，行为预演）。在社区环境中使用这些策略的程度（如频率、强度）尚不清楚。越来越多的国家和州正在努力通过传播和实施举措来扩大ebp的覆盖范围。有18个州在实施以创伤为重点的认知行为疗法（TF-CBT），这是一种针对儿童创伤暴露和后遗症的EBP。华盛顿州资助的为期五年的TF-CBT倡议是许多此类努力的代表。许多基于社区的TF-CBT实施工作，以及其他ebp的实施工作，都特别关注监督者。然而，有限的科学文献为这些努力提供了很少的指导。当前试验的目的包括：1)研究现有实施支持下的监管；特别是金标准元素的存在；2)评估不同监管策略对保真度和客户结果的影响；3)检验治疗保真度对监督类型与来访者结果关系的中介作用。我们提出了两阶段的设计，即学科内和学科间的设计。在第一阶段（9个月），我们将研究监管与实施支持。在第二阶段（30个月），我们将研究两个具体的监管条件，每个条件都包括不同的EBP监管要素。我们计划招募20名主管和140名临床医生，随机分配到临床医生水平的条件（即所有主管将提供所有条件）。我们将在I期临床医生中招募1名青年（N = 140），在II期临床医生中招募3例（N = 420）。研究结果将为有效促进高保真实施并在社区环境中最可行的监督战略提出重要建议。

DESCRIPTION (provided by applicant): The primary goal of this R01 proposal is to study the impact of varying supervision strategies on clinician fidelity and client outcomes in a community-based setting. Prior research has established that training approaches that do not include a period of intervention-specific supervision or consultation are ineffective and that implementation efforts that include only an initial period of supervision show an eventual attenuation of gains in knowledge and fidelity in practice. Ongoing supervision may be required for effective and sustained implementation of evidence-based practices (EBPs) in community-based settings. However, supervision is one of the least investigated aspects of training. "Gold standard" elements of supervision from efficacy trials include review of sessions, standardized procedures for monitoring client outcomes and model fidelity, and ongoing skill-building (e.g., behavioral rehearsal). The degree (e.g., frequency, intensity) to which these strategies are used in community-based settings is unknown. There are a growing number of national and statewide efforts to increase the reach of EBPs through dissemination and implementation initiatives. There are 18 statewide initiatives to implement Trauma-focused Cognitive Behavioral Therapy (TF-CBT), an EBP for child trauma exposure and sequelae. The five-year, state- funded, Washington State TF-CBT Initiative is representative of many of these efforts. Many of the community- based TF-CBT implementation efforts, and those for other EBPs, include a specific focus on supervisors. However, the limited scientific literature provides very little guidance for these efforts. Aims of the current trial include 1) studying supervision with existing implementation supports; particularly presence of gold standard elements; 2) evaluating the effects of varying supervision strategies on fidelity and client outcomes; and 3) testing the mediating effect of treatment fidelity on the relationship between supervision type and client outcomes. We propose a two-phased, within-subjects and between subjects design. In Phase I (9 months), we will examine supervision with implementation support. In Phase II (30 months), we will examine two specific supervision conditions, each including varying EBP supervision elements. We plan to enroll 20 supervisors and 140 clinicians, with randomization to condition occurring at the clinician level (i.e., all supervisors will provide all conditions). We will enroll 1 youth per clinician in Phase I (N = 140) and 3 cases per clinician in Phase II (N = 420). The findings will yield important recommendations for supervision strategies that are effective in promoting high-fidelity implementation and are most feasible in community-based settings.