INTERVENTION MANUAL
8.4 TRAINING OF INTERVENTIONISTS
reinforcing and maintaining the acquired competencies and preventing drifts in performance (Johnson & Remien, 2003). Initial and ongoing training are essential for a proper and accurate implementation of the intervention’s components.
8.4.2 Content of Training
The content covered in initial and ongoing training differs slightly, even though both focus on supporting the interventionists’ cognitive, behavioral, or practical skills required to provide the intervention’s components, in the specified mode and dose.
8.4.2.1 Initial Training
Initial training is comprehensive and intensive, providing a balance between didactic and experiential learning if it is to adequately prepare interventionists (Webster- Stratton et al., 2014). The didactic part could be offered first followed by the experiential part.
Alternatively, the experiential part can be interwoven with the didactic, whereby each intervention component is described at the conceptual level and pertinent skills for providing it are practiced under supervision of the trainer.
Didactic Part of Initial Training
The didactic part of initial training revolves around the theoretical underpinning and the operationalization of the intervention. This involves a review of the intervention theory and the intervention manual, respectively. The review of the theory provides the rationale for the intervention, which helps interventionists appreciate the value of the intervention and understand its active ingredients and mechanism of action.
The review of the manual informs interventionists of the way in which the active ingredients are put into operation and of the essential content that must be conveyed and the activities that must be performed, and how, in order to produce the beneficial outcomes. The topics to be presented and discussed include:
1. The theory of the health problem that the intervention addresses: A condensed presentation of the problem and its indicators and determinants, and of rele- vant empirical evidence and experiential accounts of the problem as experi- enced by the target client population is useful. This information helps interventionists familiarize themselves with the problem; understand why and how the problem is experienced as well as the aspects of the problem addressed by the intervention; and anticipate variability in clients’ experience and perception of the problem.
2. The theory of change and the theory of implementation: This involves a detailed description and discussion of the intervention’s goals; active ingredi- ents and respective components; the main content, activities, and treatment recommendations; the mode and dose of delivery; and the mechanism of action that mediates the intervention’s effects on the ultimate outcomes. This information promotes interventionists’ understanding of the intervention’s rationale and appreciation of its significance. Interventionists who realize the importance of the intervention may be able to convince clients of its value in addressing the health problem, particularly if they develop a helpful working alliance. Fuertes et al. (2007) reported that clients who understand treatment and agree to it and trust their interventionists are likely to “buy into” treatment, see it as worthy, and follow through it.
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3. The operationalization of the intervention: This entails (1) highlighting the components that represent the intervention’s active ingredients, and pointing to the importance of carrying them out as planned; and (2) reviewing the intervention manual, clarifying the key principles guiding interactions with clients with the aim of reinforcing interventionists’ interpersonal skills, explaining how the activities are to be performed; and delineating when and how adaptations are to be made. These points inform interventionists of what the intervention is about and how it is to be given.
Experiential Part of Initial Training
The experiential part of initial training focuses on skill performance. It provides interventionists opportunities to observe and practice the cognitive and behavioral skills needed to carry out the planned intervention activities and to review the resources needed for providing the intervention. Various strategies can be used to promote acquisition of these skills. Examples of strategies include:
1. Case studies or vignettes: These consist of presenting information about hypo- thetical or actual clients, describing the clients’ experience of the health problem and individual concerns. Interventionists are requested to analyze the information and delineate the course of treatment or modifications of the intervention delivery as stipulated in the manual. Other case studies can illus- trate clients’ reactions to the intervention or challenges in implementing the treatment recommendations; interventionists are asked to devise relevant strat- egies and apply relevant interpersonal skills to handle these situations. Case studies can be completed on an individual, subgroup, or whole group basis.
This is followed by inviting interventionists to reflect on their performance and to discuss their answers to clarify the rationale for their answers. The trainer provides feedback, and reviews how best to address the cases within the parameters of the intervention theory and manual.
2. Demonstration: This can be done by the trainer showing the specific steps for relaying the content and performing the intervention activities. Alternatively, audio or video recordings of previously offered intervention sessions are played. If the recordings are unavailable, transcripts of the taped sessions are reviewed to illustrate the implementation of the intervention. This is followed by a group discussion facilitated by the trainer to highlight accurate performance; suggest ways to improve performance; identify deviations in carrying out specific intervention activities, rationale for the deviations, and impact on fidelity of intervention delivery; and review the appropriateness of strategies used to manage emerging issues.
3. Role play or role modeling: This consists of having the interventionists apply the skills or intervention activities that are demonstrated by the trainer or in the recordings. The trainer then provides feedback to reinforce correct performance or to rectify incorrect performance.
4. Supervised delivery of the intervention: If resources are available, trained interventionists attend a practical, hands-on training session. They are asked to deliver a session of the intervention to actors posing as clients, under the supervision of the trainer. The trainer then comments on their technical and interpersonal skills, and works with interventionists on strategies to help them improve their performance.
8.4.2.2 Ongoing Training
Ongoing training is recommended to maintain an adequate level of competence for all interventionists involved in the delivery of the intervention. It also provides oppor- tunities to discuss challenges or drifts in implementation and strategies to address them; to give support and feedback on performance; and to reinforce theoretical and practical knowledge.
Ongoing training can take the form of in-service or booster sessions, or coaching and consultations. Booster sessions are organized into two parts. The first part con- sists of a review of the intervention theory and of the implementation of the inter- vention. The second part of booster sessions entails discussion of challenges encountered in delivering the intervention, cases of clients who present with specific concerns, and strategies to manage these challenges and concerns. Coaching and consultations involve supervision of interventionists’ performance and regular meet- ings. The trainer or designate (e.g. other health professional with expertise in the intervention delivery) attends randomly selected sessions facilitated by intervention- ists. If attendance is not possible or agreeable to clients, then the intervention sessions are audio-recorded and the trainer reviews the audio recordings. The trainer provides support, reinforcement, and detailed feedback on the interventionists’ performance.
At the meetings, held with individual or group of interventionists, the trainer: dis- cusses challenges (e.g. arising individual clients’ concerns, unfavorable clients’
reactions, unavailability of resources) faced during the delivery of the intervention;
factors contributing to the challenges; strategies that interventionists used to manage the challenges; the appropriateness and consistency of the strategies used with those proposed in the manual; the perceived helpfulness of the strategies used; and addi- tional alternative strategies that can be utilized to manage the challenges.
The initial and ongoing training are necessary to promote interventionists’
understanding of the theoretical underpinning and practical competence in deliv- ering the intervention. Interventionists who acquire the cognitive and behavioral skills are well positioned to deliver the intervention with fidelity while appropriately attending (with minimal deviations) to individual clients’ concerns, characteristics, and life circumstances.
8.4.3 Methods for Training
The initial and ongoing, didactic and experiential, training as described in Section 8.4.2 has been usually advocated and extensively used in research. In this context, the training is given in individual or group, face-to-face sessions, followed by close super- vision of interventionists’ performance.
With the increasing interest in implementing evidence-based interventions in practice, different methods have been devised and evaluated for their effectiveness in improving the skills of health professionals responsible for delivering the interven- tions. The training methods are described, and relevant evidence synthesized from a review of the literature (Herschell et al., 2010) and individual studies (McDiamid Nelson et al., 2012; Webster-Stratton et al., 2014) is presented next.
Review and/or discussion of the intervention manual in in-person sessions: The review and discussion is led by the trainer, similar to the procedure used in the training of interventionists detailed in Section 8.4.2. The trainer proceeds by reading each section of the manual while interventionists follow through with their own copy of the manual. For each section, the trainer: (1) clarifies the information and details the intervention activities to be performed; (2) reiterates the rationale and the
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way of carrying out the activities; (3) identifies the required resources; (4) explains possible deviations in performing the activities to address challenging situations and individual client concerns while maintaining fidelity in delivering the intervention’s active ingredients; (5) discusses strategies to manage the challenges successfully and gives examples to illustrate the points of discussion; and (6) reiterates the main points to reinforce learning. This method for training is necessary and useful for prompt clarification of theoretical or practical content. It was found effective in increasing interventionists’ knowledge and capacity to deliver the intervention in the short term, but insufficient for the acquisition and maintenance of the skills or compe- tence in providing the intervention in the long term.
Self-directed training techniques: These entail making the intervention manual and other training materials such as video recordings of intervention sessions avail- able electronically. Interventionists access these materials and review them on their own. Evidence suggests that self-directed techniques are viewed favorably by inter- ventionists and have the advantages of cost-effectiveness (i.e. easily accessible by a large number of interventionists). However, the results of Herschell et al.’s (2010) review indicated that less than 50% of interventionists completed the self-directed training and demonstrated only slight improvement in their theoretical knowledge and practical competence in delivering the intervention.
Workshops: The workshops are comparable to the initial training and involve didactic and experiential learning (Section 8.4.2). When offered to health professionals responsible for implementing evidence-based interventions in practice, workshops were found to increase health professionals’ knowledge; however, they had a short term and small impact on changing their behaviors or skills needed to implement the interventions.
Post-workshop supervision and feedback: These were called workshop supple- ments by Herschell et al. (2010). These methods are comparable to the supervised delivery of the intervention, coaching, and consultations described in Section 8.4.1.
These behaviorally oriented methods were reported as influential in improving inter- ventionists’ skills.
Multicomponent training methods: These consist of different combinations of:
review of the intervention manual, workshops, supervision, and feedback. Multicom- ponent methods demonstrated effectiveness in improving interventionists’ (in research) or health professionals’ (in practice) knowledge, competence, and adherence to the intervention protocol (i.e. fidelity) in some but not all studies reviewed by Herschell et al. (2010).
Overall, evidence converges in showing that: (1) training methods involving only lecture-style or self-directed, didactic, passive presentation of content related to the conceptualization and operationalization of the intervention are ineffective in enhancing interventionists’ knowledge and behavioral skills; (2) training methods involving active learning strategies (e.g. role play, case studies) are effective; and (3) training methods involving a review of the intervention theory, behavior role play, supervision, and feedback are most effective in improving interventionists’ or health professionals’ knowledge, skills, and ability to deliver the intervention with fidelity (Herschell et al., 2010; McDiamid Nelson et al., 2012; Webster-Stratton et al., 2014).
8.4.4 Evaluation of Training
Regardless of the method used, it is wise to evaluate the helpfulness of training in facilitating acquisition of theoretical and practical knowledge of the intervention.
The evaluation results determine the interventionists’ level of competence and areas
of performance that should be improved; and provide guidance for revising the training content and methods to enhance its effectiveness.
There are no specific guidelines and standard instruments for evaluating training.
The following points can be considered. The evaluation can be done upon comple- tion of each part of the training, that is, the didactic and the experiential part, or at the end of all training. The evaluation can cover assessment of the interventionists’
knowledge of the intervention and practical competence in providing it. Assessment of knowledge is accomplished by administering a test containing close- and open-ended questions, and vignettes followed by relevant questions. The questions are designed to measure interventionists’ understanding of the theory underpinning the intervention, the operationalization of its active ingredients into respective com- ponents, and the rationale for specific content and activities. Short vignettes and associated items are generated to assess interventionists’ skills at implementing var- ious intervention activities accurately and at handling challenges that may arise dur- ing delivery. Additional items can be incorporated to assess the interventionists’
interpersonal skills. Formal evaluation of interventionists’ skills is planned as part of the supervised delivery of the intervention, or in a separate session scheduled prior to entrusting the delivery of the intervention to clients. The latter session is comparable in content and format to the supervised delivery of the intervention: The interven- tionists deliver a session to actors posing as clients and the evaluator observes and rates their performance.