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

描述（由申请人提供）：本R 01提案的主要目标是研究在社区环境中不同监督策略对临床医生忠诚度和客户结局的影响。之前的研究已经确定，不包括针对干预措施的监督或咨询期的培训方法是无效的，并且仅包括初始监督期的实施工作最终会削弱实践中的知识和忠诚度。为了在社区环境中有效和持续地实施循证实践，可能需要进行持续的监督。然而，监督是培训中调查最少的方面之一。来自疗效试验的监督的“金标准”要素包括会议审查、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培养（例如，行为排练）。程度（例如，这些战略在社区环境中的使用频率、强度）尚不清楚。 有越来越多的国家和全州的努力，以增加通过传播和实施倡议的基本商业惯例的影响。有18个全州范围内的倡议，以实施创伤为重点的认知行为疗法（TF-CBT），EBP儿童创伤暴露和后遗症。为期五年、由州政府资助的华盛顿州TF-CBT倡议是其中许多努力的代表。许多基于社区的TF-CBT实施工作，以及其他EBP的工作，包括对监督员的具体关注。然而，有限的科学文献为这些努力提供的指导很少。本试验的目的包括：1）研究现有实施支持下的监督，特别是金标准元素的存在; 2）评估不同监督策略对忠诚度和客户结果的影响; 3）测试治疗忠诚度对监督类型和客户结果之间关系的中介作用。我们提出了一个两阶段，内科目和科目之间的设计。在第一阶段（9个月），我们将审查监督和执行支助。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电子交易监管元素。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，所有监管人员将提供所有条件）。我们将在I期（N = 140）中每名临床医生招募1名青年，在II期（N = 420）中每名临床医生招募3例病例。研究结果将为监督策略提供重要建议，这些策略有效促进高保真实施，并且在社区环境中最可行。 公共卫生相关性：该补助金将为研究有效实施儿童和青少年精神健康障碍循证实践（EBP）中一个必要但经常被忽视的方面提供支持-以社区为基础的环境中的监督。随着在以社区为基础的环境中实施EBP的努力不断增加，至关重要的是要确定可行的，负担得起的，有效的战略，以支持EBP的做法，最终目标是改善在这些环境中服务的儿童和青少年的结果。EBP有很大的希望;然而，为了实现其公共卫生影响，有必要确定有效的监督策略，以提高EBP的忠诚度，改善客户的结果，并提供一种在地方一级持续实施EBP的手段。

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. PUBLIC HEALTH RELEVANCE: This grant will provide support for studying a necessary, but often overlooked aspect in effective implementation of evidence-based practices (EBPs) for child and adolescent mental health disorders- supervision in community-based settings. As efforts to implement EBPs in community-based settings continue to increase, it is critical to identify feasible, affordable, and effective strategies to support EBP practice, with the ultimate goal of improving outcomes for children and adolescents served in these settings. EBPs hold considerable promise; however, for their public health impact to be realized, it is necessary to identify effective supervision strategies that enhance EBP fidelity, improve client outcomes, and offer a means of sustaining EBP implementation at the local level.