Background
Training of trainers needs to ensure that those disseminating the training have acquired the knowledge, attitudes and skills - both to deliver the intervention and teach others how to do it. There is however the well-known problem that when information is re-transmitted to each level, the chances of dilution and or misinterpretation of key messages increase [4]. This has led to some considerable criticism of the effectiveness of the model in educational settings [11]. Indeed, in his educational blog Mackenzie [12], extends the water metaphor to explore a number of problems with the cascade model. These include the ‘sponge’ (skills and information not passed on by the second stage trainer) ‘trickle down’ (trainers not able to train participants to required standard) and the ‘flood’ (participants feel overwhelmed by what is delivered to them by trainers). McDevitt [13] commenting on training teachers in Botswana takes this further ‘if you’re too far away from the source you can avoid getting soaked’. He notes the conflict between involving teacher participation in modifying the input to meet local needs and ensuring the integrity of the message being transmitted to end users.‘the articulation of training programs to provide differing levels of competence they require to implement the change.’ … ‘thus the underlying notion of cascade training is that critical change related information will flow through the organisation in a planned way to facilitate subsequent parts of the institutionalization process.’ (p180)
Contextual factors have posed problems when the focus has primarily been on the implementation of the intervention at the professional-patient-carer level [1]. Yet detailed reflections on the limitations of cascade methodology is harder to locate in health and social care settings than in education, despite its widespread application in dissemination. A systematic review of train-the-trainers programmes (TTT) in health and social care [16] found that the heterogeneity of the studies and limited data prevented meta-analysis although narrative review found that the TTT programs in 13 studies helped to increase knowledge, improve clinical behaviour, or produce better patient outcomes. The authors of this review concluded that a ‘blended learning’ approach, combining different techniques, was most likely to be successful in achieving positive outcomes but failed to explore processes in detail. However three studies in this review identified a potential long-term problem with the model. It was often difficult to ensure the continuing implementation of the training programs due to high staff turnover and retention of staff after they had been trained. Therefore, long-term sustainability and staff commitment need to be considered when developing TTT programmes.‘find strategies to develop awareness in the trainees themselves of their own context and to derive the context and framework of the development sessions from the trainees themselves.’ (p174)
STORM skills training and suicide prevention
Researching implementation
Coherence | Cognitive participation | Collective Action | Reflexive Monitoring |
---|---|---|---|
Participants distinguish the intervention from current ways of working | Key individuals drive the intervention forward | Participants perform the task required by the intervention | Participants access information about the effects of the intervention |
Participants collectively agree about the purpose of the intervention | Participants agree that the intervention should be part of their work | Participants maintain their trust in each other’s work and expertise through the intervention | Participants collectively assess the intervention as worthwhile |
Participants individually understand what the intervention requires of them | Participants buy into the intervention | The work of the intervention is appropriately allocated to Participants | Participants individually assess the intervention as worthwhile |
Participants construct the potential value of the intervention for their work. | Participants continue to support the intervention | The intervention is adequately supported by its host organization | Participants modify their work in response to their appraisal of the intervention |
Methods
Design
Setting
Intervention
Participants
Job/role | Health Board | ||
---|---|---|---|
Facilitators (n = 19) | |||
CPN Service development officer Staff nurse Project nurse Nurse trainer Lecturer in mental health nursing Parasuicide nurse specialist Public health nurse Practice development nurse Nurse consultant Suicide prevention trainer Nurse therapist Clinical nurse specialist Deputy ward manager Senior CE practitioner Senior Nurse practitioner Care home education facilitator | 1 1 1 1 2 1 1 1 1 1 2 1 1 1 1 1 1 | Grampian Lothian Ayrshire & Arran (one private sector) Greater Glasgow and Clyde Dumfries & Galloway Lanarkshire Fife Highland | 2 4 3 5 1 2 1 1 |
Managers (n = 11) | |||
Clinical nurse manager Clinical governance manager Team leader Programmes manager Choose Life Coordinator Head Occupational Therapist Training Coordinator Senior Lecturer Community Psychiatric Nurse | 1 1 1 1 2 1 1 1 2 | Grampian Lothian Ayrshire & Arran Greater Glasgow and Clyde Dumfries & Galloway Lanarkshire Fife Highland | 1 4 1 0 1 0 2 2 |
Participants (n = 30) | |||
Community Psychiatric Nurse Staff Nurse Ward Manager GP Clinical Psychologist Occupational Therapist OT technician Chaplain Health Visitor Memory clinic nurse Support Worker Blood borne virus nurse | 8 6 1 3 3 3 1 1 1 1 1 1 | Grampian Lothian Ayrshire & Arran Greater Glasgow and Clyde Dumfries & Galloway Lanarkshire Fife Highland | 5 10 1 1 2 1 4 6 |
Results
Coherencea | Cognitivea participation | Actiona | Reflexive monitoringa | |
---|---|---|---|---|
Consultant trainers and training organisation | Work with facilitators and each other to construct coherent vision of training for this organisation | Training the facilitators | Enabling the facilitators to put training into action, support and supervision | Providing feedback to policy level commissioners. Modify the training in response to feedback from facilitators, participants and managers. |
Senior managers | Work with policy level actors, other managers and peers to understand why and how to prioritize training | Ensure that training is taking place in the organisation | Ensure that training is adequately supported and being delivered optimally. | Evaluate and synthesize feedback from managers, facilitators, participants and support agencies. Provide feedback to policy level/ commissioners. Consider if/when/how to prioritize embedding within organisation. |
Clinical managers | Work with senior managers, fellow managers facilitators, participants and support agencies to understand how and why to prioritize training | Ensure that conditions are optimal for training to take place in the organisation | Ensure that the right people are being trained, training is taking place, and being optimally supported | Provide feedback to senior managers. Obtain and synthesize feedback Negotiate with facilitators and senior managers what system changes required to embed within organisation. |
Facilitators | Work with managers, fellow facilitators, participants and support agencies to understand how and why to prioritize training | Deliver the training to participants | Ensure that training is being optimally delivered | Provide feedback to managers and training organisation. Negotiate with clinical managers about what system changes required to embed within organisation. Negotiate requirements to normalize on-going training. |
Co-constructing ‘coherence’: the ‘making sense’ work done between facilitators, participants and managers
‘STORM is central to the whole process. What STORM has given to us is a common language, it’s also … erm.. given us a framework … Now what that’s given us is uniformity and structure so if someone, you know, presented with very low suicidal intent … but in the past we didn’t have any record of what intervention had happened … so it’s given us structure to practice … and for me that will shape local practice.’ (Facilitator-59)
‘to be honest with you I didn’t particularly want to do it because I had a very full and busy diary of other training that I’m looking at providing, I was sent because my manager knows I can deliver training’ (Facilitator-90)
‘it’s just part of the bread and butter of our everyday work really’ (Participant 681) and there was some dissent about whether preventing suicide was always possible or even desired.
‘Although we have a duty of care obviously to people to try and stop them from harming themselves, I think it’s very much a personal choice thing and I can see where people would be … just be fully justified to say, no I’ve had enough.’ (Participant-893)
‘It’s just targeting the right people, getting managers on board to see how it would be useful for the staff, but also the staff themselves in relation to being videoed’ (Facilitator-04)
A key lever was the national HEAT (Health –Efficiency-Access- Treatment) target to train 50% of key front life staff in the NHS in suicide prevention by 2010 [23]. This effectively made training mandatory for the period that the target was in place. Support and supervision for facilitators was also offered by STORM and in some places local support for facilitators was provided by the Choose Life coordinator - both of these were perceived as helpful.‘really just get the board on side that this is something that we have to do … it seems to be at the right level now, people are all aware now so it’s good for us at the clinical level if we’ve got that buy-in and they understand because obviously we’ve got to backfill places … ’ (Manager-01)
Cognitive participation: working together to deliver the STORM training
‘Initially when you have that huge learning of delivery … IT … you know some of the equipment … once you overcome that, you find with some of the new recruits it takes them a while to feel competent and confident but when you’re delivering the suicide agenda, it can have an impact on yourself, given the nature of the subject. I think supervision’s essential’. (Facilitator-59)
‘ … before they come on the training , they know exactly what is expected of them, if they’re there at the training the expectation is that they will participate, if they’re having difficulties we say right from the beginning … speak to one of the facilitators … but if people don’t participate in all of the components of the training including the video people will not be certificated.’ (Facilitator-66)
‘We do always get people who don’t want to do the training, and we’ve found when people haven’t read the pre-course information, it kind of comes as a real shock to them and then having to do that immediately, and I think we’re very much on top of working with that now, but initially it was ‘I don’t have to do that and if you make me do the filming you’re infringing my human rights’, and actually I got … myself and my colleague did ring up for some supervision from Gill and talked that over, that was very helpful.’ (Facilitator 48)
‘I thought it might be useful for the team, so I asked to go on it’ (Participant-583).
‘Quite a few people voiced the opinion that, you know, if you’ve been qualified for quite some time maybe it won’t be as helpful, but I think the manager was very much ‘well, we’ll go along and see.’ (Participant-681)
‘they just said they didn’t want to be videoed so just lasted half a day’ (Participant 681).
Collective action: getting the elements of the STORM intervention ‘normalised’ at all levels within the organisations
Organisational support was however variable. One facilitator noted how his host organisation had ‘allowed us to train’ but it was clear that staffing numbers on wards might impact considerably at the last minute, and the quality of training venues varied from ‘a cupboard in an office’ and ‘an old ECT (Electroconvulsive Therapy) suite’ to the ‘absolutely fantastic’. Some of the facilitators were employed part-time specifically to train whereas others depended on the goodwill and interest of managers to be able to find time to release them to do training. When training was mandatory it was possible to provide it during working hours, but towards the end of the project this was changing and there was concern about whether participants would be prepared to attend in days off or pay for training.‘When I was identified as somebody who might like to do the training for trainers, I went along, completed that, sat down with my line manager … and we decided who we were going to target for STORM training … and then, because I coordinate training as part of my job in the hospital I just set about coordinating that. I work in in-patient units and we just teamed up together and we trained across community and in-patients’. (Facilitator-27)
Nevertheless, one facilitator reported that managerial engagement had led to development of a new suicide prevention and treatment pathway utilizing constructs from the STORM training. The intervention was also successfully incorporated by another into an undergraduate nursing course that he was involved with locally (Facilitator-48).‘In terms of translation into practice it’s quite difficult. All we can do really is attend meetings, so we attend meetings with our local clinical managers, and we will try and influence how STORM is translated into practice, and that’s possibly, that’s as far as we can go we try and make it a strong influence but ultimately it’s the decision of those clinical managers, so however much they take that forward.’ (Facilitator-48)
Reflexive monitoring: evaluating the the impact of the STORM training intervention
‘I think it’s fitted in very well actually, yeah, yeah, I think that … erm … quite often people have kind of hinted at suicide before and maybe I haven’t always taken that seriously, and I think that I’m certainly more likely now to take it seriously or to look for reasons to take it seriously rather than think ‘well thank goodness, you don’t really mean that’, and I’m certainly not worried now about being very open and saying to people ‘have you ever thought of killing yourself?’, whereas before it would’ve been couched in euphemism’. (Participant 702)
‘it used to be that I felt that I couldn’t quite ask the death question, but now I find a way to ask that’ (Participant 621)
‘I think It’s been very positive, certainly the verbal feedback would suggest that, the fact that we have people who are asking for the training, and continuing to ask for the training, and we have people asking for updates, you know, ‘what happens now?” (Facilitator-27)
‘I could see lots of opportunities … but because you’re kind of confined in terms of rolling it out as a programme we can’t do that.’ (Facilitator-72)
‘I think one of the problems is that I’ve found that [indistinct] quality of recent training compared to the training I did some time back … you know … there seems to be some adjustments … approaches that differ slightly, and I just wonder how trainers … you know for example … ensure that … you know … they are still meeting the mark and hitting the spot of STORM development.’ (Facilitator-59)
However, there was no clear evidence that this was being utilised to contribute to any longer-term planning to embed suicide prevention training expertise and culture within local health boards.‘we do rely on reports from attendees to make sure that we’re getting the right people through, so those that are supposed to be attending to make sure we’re reaching the targets that we have to reach, because it’s the only way that we can cross reference that’ (Manager-01)
Discussion
‘tends to place undue emphasis on individual and collective agency without locating this within, and as shaped by, the organisational and relational context in which implementation occurs’.