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下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，不包括针对干预措施的监督或咨询期的培训办法是无效的，只包括初期监督期的执行工作最终会削弱知识和忠诚度在实践中的成果。为了在社区环境中有效和持续地实施循证做法，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。疗效试验监督的“黄金标准”要素包括对疗程的审查、监测客户结果和模型保真度的标准化程序，以及持续的技能建设(例如，行为预演)。这些策略在以社区为基础的环境中使用的程度(例如，频率、强度)是未知的。在全国和全州范围内，越来越多的努力通过传播和执行举措扩大循证方案的影响范围。全州范围内有18项倡议实施以创伤为重点的认知行为治疗(TF-CBT)，这是一种针对儿童创伤暴露和后遗症的EBP。华盛顿州州政府资助的为期五年的TF-CBT倡议是其中许多努力的代表。许多以社区为基础的工作队-CBT实施工作，以及其他EBP的工作，都包括对监督者的具体关注。然而，有限的科学文献对这些努力提供的指导很少。当前试验的目的包括：1)研究现有实施支持下的监督；特别是存在黄金标准要素；2)评估不同监督策略对保真度和客户结果的影响；以及3)测试治疗忠诚度在监督类型和客户结果之间的中介作用。我们提出了一种两阶段、学科内和学科间的设计。在第一阶段(9个月)，我们将审查监督和执行支持。在第二阶段(30个月)，我们会研究两项具体的监管条件，每项条件都包括不同的环境保护计划监管元素。我们计划招募20名监督员和140名临床医生，根据临床医生级别的情况进行随机化(即，所有监督员将提供所有条件)。我们将在第一阶段(N=140)为每位临床医生招募1名青年患者，在第二阶段(N=420)为每位临床医生招募3例患者。调查结果将为监督战略提出重要建议，这些战略在促进高保真实施方面是有效的，在社区环境中最可行。

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.