co-existing problems (cep) skills development - … · people with substance use, ... taylor 2000)...
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CEP Skills Development
Requirement for services and clinicians to be CEP capable. NZ guidelines already exist. (Te Ariari o te Oranga )
Questions raised about:
How do we do it?
What have we tried already?
How could we do it better?
How do we know when we have got there?
Improve the skills of clinicians from a wide variety of disciplines in assessing and treating clients with co-existing disorders
Support clinicians in attaining skills and to gain confidence in using them.
Achieve a cultural shift in MH and Addiction services nationwide
What do we need to do?
Skills Development versus Competencies
Competencies are related to the individual clinician
Skills - are about the work we do
Development and Attainment of skills- knowledge and practical application
Skills measurement - quantifying/ qualifying skills development eg. Using Workplace Based Assessments (WBAs)
Does
Shows How
Knows How
Knows
Miller GE 1990. The assessment of clinical skills/competence/performance. Academic Medicine, 65 Supp 563-567
Miller’s Pyramid
Competencies
Currently already exist.
Linked with professional bodies – DANA,
DAPAANZ, RANZCP, Te Pou, ?Peer support
Whilst these competencies are worded differently,
they tend to say the same things!
When demonstrating skills attainment, clinicians
should automatically demonstrate the
competencies required to implement the skills.
Skills Set
Can be quantified dependent on experience and training of clinician
Makes CEP a practical proposition as clinicians can identify which skills to work towards
Skills can be mapped against competencies e.g, assessment skills include communication, collaboration and cultural competencies
Aligns with Te Ariari o te Oranga approach
Examples of skills
Undertake a comprehensive assessment
Complete a risk assessment
Implement a brief intervention
Screen for mental illness/substance use disorder
Implement a relapse prevention strategy
SKILLS
Foundation
Capable
Enhanced
Brief Interventions Knowledge of brief interventions Able to apply simple brief intervention strategies
Application of brief
interventions
Demonstrates skills in utilising brief interventions in a variety of settings
Comprehensive
mental health,
substance use and
gambling
assessment
Knowledge of DSM-IV/ICD-10 for MH, SUDs (inc. Subs induced) and PG Assessment of recent and lifetime mental health symptoms/problems (patterns of use and tx) Assessment of recent and lifetime substance use Assessment of recent and lifetime gambling behaviour (patterns of use and tx)
Assessment of mental
health, substance use and
gambling history in the
context of psychological and
physical functioning,
symptomatology and
withdrawal history
Demonstrates knowledge and application of DSM-IV/ICD-10 criteria for mental health, substance use disorders (including substance-induced states) and Pathological Gambling
Monitoring and
testing of
substances, alcohol
and medications
Knowledge of common substance testing procedures and laboratory investigations Knowledge of common blood/urine tests
Application of substance
testing procedures and
laboratory investigations.
Comprehensive knowledge
of methods for substance
testing
Demonstrates knowledge and interpretation of common substance testing procedures and laboratory investigations
• Copyright © 2006 The Royal College of Physicians and Surgeons
of Canada. http://rcpsc.medical.org/canmeds. Reproduced and
adapted with permission.
Clinical
Expert
Skills mapped against competency. Comprehensive Ax
Health Advocate. (Competency)
Fosters positive attitudes to counter stigma towards
people with substance use, mental health and gambling
disorders. Demonstrate an understanding of issues
pertaining to coexisting disorders in diverse groups
including cultural, ethnic, indigenous and disadvantaged
groups across all stages of life. (Role Competency)
Does the assessor advocate on behalf of the client when
the family/whanau is present?
Does the assessor counter prejudicial attitudes in a
multidisciplinary team setting?
Does the assessor display a non-judgemental attitude in
all settings? (Indicative questions)
Skills Development
Self directed skills development
eg.:DVD’s
online learning
Knowledge acquisition:
eg.: training events
workshops
Mentoring/Supervision
eg. Supervision
work based assessments
•How do we know when someone has the skills? •Why do we need to know if skills have been attained? •What will this mean for 1.MH Clinicians? 2.Addiction clinicians? •Do we need more than competencies?
Break for Questions
Miller’s Pyramid and Assessment
Does
Shows How
Knows How
Knows
Observed interviews with feedback
Written Exams eg MCQ
Complex written exams
Workplace based assessment
Assessment
Miller GE 1990. The assessment of clinical skills/competence/performance. Academic Medicine, 65 Supp 563-567
Workplace Based Assessments to measure acquisition of skills
• ACE: Assessment of Clinical Expertise
• CBD: Case Based Discussion
• MSF: Multi Source Feedback
• MDT/Case Conference
• Logbook
• Client Satisfaction Questionnaire
Piloting the Skills
Skills were developed at 3 levels recognising the variety of professional disciplines and experience that exist
Foundation, Capable, Enhanced
Baskets of skills could be chosen by clinicians dependent on the work environment
Why do we need a Pilot?
• Does the framework work?
• Works to win the confidence of other stakeholders
• Maps the resources required
• Provides baseline data
• Enables adaptation and alteration
Outcomes and the future
• Can this skills development approach be used for core mental health and addiction skills?
• How are we going to continue evaluating?
• Do we need funding or can we implement from existing resource?
• Does it work???
Competencies/Skills:
• International competencies (Graham &White 2011; www.ccsa.ca 2010)
• Challenges of linking competencies to clinical care (Jones et al., 2011) thus the move to a skills focus.
• Practical implications of implementing competencies (Mulder et al., 2010)
Work Based Assessments:
• Significant correlation between scores from the CEX and exam scores (Searle 2008)
• WBAs as an essential element of British psychiatrists training
• ‘Need for good planning and understanding around the WBAs prior to initiation ‘(Menon, Winston and Sullivan 2012)
• Highlights validity measuring complexities and points to the value of utility (Holsgrove 2010)
Workforce Development: • Workforce development typically is of individuals ,
through education and training , in a knowledge transfer structure (Allsop &Helfgott 2002, Roche 2009)
• Training as a stand-alone event, results in limited or non-sustained change (Arthur et al. 1998, Baer et al. 2004, Bennett et al. 2007,
Roche 2002)
• Requires systems wide approach that supports the transfer of skills and knowledge Eg appropriate supervisory, peer and organisational support post training (Roche 2002, Cromwell 2004, Lim & Morris 2006, Taylor 2000)
Benefits and Barriers
Effective for enhancing CEP capability
Assessor and clinician benefits
Best clinical practice
Use alongside other approaches & strategies
Sustained change
• Identifying enhanced practitioners
• Understanding the process and value
• Resourcing
• Service support
• Clarity about its future
Evaluation Objectives
• Validity
• Inter-rater reliability
• Generalisability
• Feasibility
• Utility
Acknowledgements
Pilot project assessors and clinicians
Clients/tangata whaiora
Services who supported the pilot
Co-existing Disorders Team, CCDHB
Participants
Wellington Assessors:
counsellor (2),
social worker (2),
nurse (3),
psychiatrist(1)
Christchurch Assessors: nurse (7)
Wellington Clinicians (n=11): – DHB (7); NGO (4)
– Addiction (4); Mental health (7)
Wellington Clinicians:
At initiation
n=16
At completion
n=11
Professional discipline Support worker 2 2
Cultural worker 1 1
Counsellor 6 3
Social worker 3 2
Nurse 3 2
Psychiatrist 1 1
Self reported/perceived level of
competence at initiation
Foundation 8 7
Capable 6 3
Capable/Enhanced 2 2
Study Design
Written survey – Qualitative and quantitative responses
Training package
Skills Framework guiding document
CEP skills framework
Each of the work based assessments
The pilot overall
Focus groups – Separate assessor and clinician focus groups
Barriers and benefits
Value and utility of the framework and WBAs
Assessor/clinician relationships
The pilot project overall
Key Findings Skills Framework
From its original form, requires further development
Clinicians would like feedback on their level of capability
Clinicians will straddle a number of skills across the range of foundation, capable and enhanced
Services could link the framework and WBAs to employment and professional development opportunities/plans
Key Findings Work Based Assessment
Benefits clinician and the assessor
CBDs and ACEs most time consuming but beneficial
Formative and summative assessment
Approach to structured supervision
Clarify the assessor/supervisor role
A compulsory element to completion
Responding to client feedback
Reflective practice
Encourages sustained behaviour change and practice
Pilot shows applicability and benefits to clinical practice:
– Addiction and mental health clinicians
– Across disciplines
– NGOs and DHBs
– Assessors and clinicians alike
– Across service and disciplines
A willingness to up skill and develop CEP capability
Resourcing intensity cannot be underestimated
Key Findings overall
Conclusion
The skills framework and associated WBAs have value and utility as a tool to enhance CEP capability
They encourage implementation of best clinical practice and supervision
Would be best serviced to complement, not supersede formal knowledge building and existing forms of professional development
Addressing training from a whole systems perspective, within the context of a robust workforce development plan is required to support
effective practice.
References Allsop, S. J., & Helfgott, S. (2002). Whither the drug specialist? The workforce development needs of drug specialist staff and agencies. Drug and Alcohol review,
21, 215-222.
Arthur, W., Jr., Bennett, W., Jr., Stanush, P. L., & McNelly, T. L. (1998). Factors that influence skill decay and retention: A quantitative review and analysis. Human
Performance, 11, 57–101.
Baer, J.S., Rosengren, D.R., Dunn, C., Wells, E.A., Ogle, R., & Hartzler, B. (2004). An evaluation of workshop training in motivational interviewing for addiction and
mental health clinicians. Drug and Alcohol Dependence, 73, 99-106.
Bennett, G. A., Moore, J., Vaughan, T., Rouse, L., Gibbins, J.A., Thomas, P., James, K., & Gower, P. (2007). Strengthening Motivational Interviewing skills following
initial training: A randomised trial of workplace-based reflective practice. Addictive Behaviors, 32, 2963-2975.
Bhugra, D., Malik, A. & Brown N. (2007) “Workplace-based Assessments in psychiatry” published College Seminar Series of the Royal College of Psychs., UK.
CCSA. Competencies for Canada’s Substance Abuse Workforce. www.ccsa.ca/eng/priiorities/workforce/competencies/pages/default.aspx. Retrieved on 16/7/2012.
Cromwell, S. E., & Kolb, J. A. (2004). An examination of work-environment support factors affecting transfer of supervisory skills training to the workplace. Human
Resource Development Quarterly, 15(4), 449-471.
Holsgrove, G. Reliability issues in the assessment of small cohorts. General Medical Council Guidance Paper. 2010
Friedman, Mark (2005),Trying Hard is Not Good Enough:How to Produce Measurable Improvements for Customers and Communities. Trafford Publ.Canada p81.
Graham, H. & White, R. (2011) Comorbidity Competencies: Skills Indicators by support recovery from comorbidity in Tasmania, University of Tasmania: Australia
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The Royal college of physicians and surgeons of Canada. 2006. http://rcpsc.medical.org/canmeds