This article follows-up on a 2013 randomized trial where MSW students were taught Motivational Interviewing (MI). To assess experiences with the MI training, focus groups were held with students seven months post training. Student perceptions of the MI training, maintenance of skills learned with an emphasis on how they transferred training to their field practice and the role of field instructors was explored. Findings suggest that students were able to maintain basic MI skills but had difficulty transferring greater elements of the training to practice. The role of the field instructor was instrumental in whether students did or did not use MI in practice post training.
Keywords: clinical training transfer to field, motivational interviewing, transfer of learning, field instruction
Schools of social work have emphasized the utility and need to implement evidence-based practices (EBP) in social work education, particularly in field education (Ducharme, Rober, &Wharff, 2015). Social work educational field placements are a vital component for clinical skill development for Master of Social Work (MSW) students, and are continuations of a two-part learning process. While students learn in the classroom, they are concurrently applying what has been taught to them in their field placements. Field placements allow students opportunities to learn about the field of social work, as well as learn clinical practice skills and self-reflective knowledge that will be applied to future social work positions. Social work field placements also provide the opportunity for MSW students to receive state of the art EBP trainings. EBP MSW student knowledge will largely rely on field instruction education. Field instructors for social work field placements are tasked with translating academic or textbook skills into actual clinical practice (Ducharme et al., 2015; Kanno & Koeske, 2010). Typically, as part of their job, field instructors are tasked with significant responsibilities to, “help orient students to their agency placement, teach and provide ongoing support to them around administrative matters, conduct supervision to discuss clinical encounters with patients, review process recordings, and discuss case management needs” (Ducharme et al., 2015, p. 2). As such, field instruction and training should address the needs of adult MSW learners by taking into consideration adult learning variables, including transfer of learning techniques.
In the Fall of 2013, a randomized control trial was used to evaluate an EBP, motivational interviewing (MI), as an educational approach for instructing MSW social work students who were placed in a child welfare setting as their field practicum. A discussion and results of this RCT have been published elsewhere (Pecukonis et al., 2016) with a detailed discussion of the RCT procedures and findings. The current study is a follow up of the MSW students who participated in the MI training. This study examines student perceptions of the training, how they transferred and used the skills learned to their field settings, and to understand the role of the field instructor in helping transfer and apply what the students learned from the training. Data were gathered via focus groups with the subgroup of MSW students who had been trained in MI using live supervision.
Fundamentals of Adult Learning
Adult learners differ from traditional learners in terms of responsibility level (Cooke, 2010). Adult learners, typically over the age of 25, often have social, family, and financial responsibilities (National Center for Education Statistics, 2016). Andragogy, a school of thought and techniques used to teach adults was popularized in the United States by Malcolm Knowles. Knowles, Holton III, and Swanson (2015) outlined five assumptions involved in adult learning: 1) adult learners are self-directed, 2) they have life experiences which inform their learning; 3) they have a desire to participate in the learning process; 4) their learning needs are relevant to their lives; and 5) they are motivated to learn. Knowles et al. (2015) argued that adult learning is best when it is experiential and uses a problem solving approach. Other scholars have argued that effective learning experiences for adults allows for the student learner to provide feedback to the educator and for the educator to assess the learner’s performance (Gatti-Petito et al., 2013). Environments specific to adult learners will both give learners the opportunity to learn and give the opportunity to build confidence after a skill has been successfully achieved.
Training Transfer for Adult Learners
Research suggests that approximately 15% of material learned in a training is retained a year after training and only 10% of trainees maintain a behavior change (Broad & Newstrom, 1992). Adult training education literature suggests that most training programs do not account for transfer of training (Merriam & Leahy, 2005). Roberts, Gustavs, and Mack (2012) recommend that trainings for adults encompass a learner-centered approach to training based on the trainee level of expertise. Effective training allows for the trainee to have insight into his/her behavior and progression through the training. Baldwin and Ford (1998) suggest that three main variables influence transfer of training: trainee characteristics (ability, skill, motivation, and personality), program design (incorporating learning principles into the training material), and work environment (supervisory or peers support as well as opportunities to perform behaviors or techniques learned through the training on the job). More recently, Daffron and North (2011) created a seven variable successful transfer of learning model. The seven transfer of learning elements include: planning process, learning characteristics and motivation, design and delivery methods, learning context, immediate application, workplace environment, and eliminating barriers. Transfer of training may be specific to discipline. For example, Luongo (2007) suggests that “training in child welfare, to be successful, must encompass a much broader view of training as facilitating ongoing development” (p. 93). Applying Daffron and North (2011)’s model as well as Luongo (2007)’s suggestions to MSW students, this posits that any training should be made applicable to the field placement, larger context of the field agency, and how the training can be applied through practice skills.
Teaching Motivational Interviewing to MSW Students
The goal of the original RCT was to evaluate live supervision as an approach to MI training for MSW students compared to a teaching-as-usual approach. MI is an evidence-based practice focusing on increasing the client’s motivation to make specific behavior change (Miller & Rollnick, 2013) and has been adopted by numerous child welfare settings due to its effectiveness in addressing problems commonly experienced by the client population (California Evidence Based Clearinghouse for Child Welfare, 2009; Child Welfare Information Gateway, 2014; Hohman, 2012). MI is a directive, client-centered approach with the goal of resolving ambivalence and evoking behavior change (Miller & Rollnick, 2013). MI has been applied to numerous intervention settings, in addition to child welfare, and over 200 randomized clinical trials have assessed the effectiveness of MI (Miller & Rollnick, 2013).
A core component of MI is the OARS (Open-ended questions, Affirmations, Reflections, and Summaries). The OARS can be described as: asking open-ended questions (inviting the client to elaborate on answers/ not yes/no response questions); affirming (the therapist honors the client as a person of worth); reflective listening (therapists reflects clients’ statements that include meaning or interpretation to the client’s statement), and summarizing (therapist summarizes the client’s statements) (Miller & Rollnick, 2013). MI involves four stages: engaging, focusing, evoking, and planning. Engaging is the process of the therapist and client establishing a working relationship. Focusing is the process by which the practitioner develops a specific direction in the conversation that will promote change. Evoking, a core feature of MI, involves the practitioner eliciting the client’s own motivations for change. Lastly, planning involves the practitioner developing a plan that includes action steps for a commitment to change (Miller & Rollnick, 2013).
Live Supervision Training with Standardized Client Actors
Live supervision (LS) entails the supervisor’s use of direct, real time feedback, and instruction to trainees actively engaged in interactive practice with either a client or a simulated client. Trainees are often viewed and supervised through a one-way mirror (Champe & Kleist, 2003). Live supervision has been used as an approach to promote MI skills acquisition and with demonstrated efficacy (Beddoe, Ackroyd, Chinnery, & Appleton, 2011). MSW students for this study previously completed a one-day dyadic training on MI where they were instructed in the OARS and the stages of MI. Students were trained using live supervision while they interacted with standardized client actors (SCA) as clients on a child welfare related case. Five MSW students were assigned to each small group (total of 25 students in 5 small groups), with a field instructor, a trainer, and one standardized client actor. Each student individually interviewed the standardized client while being filmed in one room, and the other students and trainers viewed the live video in an adjacent room. The student wore an ear piece that was remotely connected to the trainer/field instructor and allowed the student to directly receive real time supervision and coaching that the standardized client could not hear.
Standardized clients in simulated training situations are not as readily used in social work education as in medical or nursing education (Haeseler, Fortin, Pfeiffer, Walters, & Martino, 2011; Imel et al., 2014). There is limited research on the use of standardized clients despite its potential to evaluate student learning and to demonstrate skills acquisition and competency (Logie, Bogo, Regehr, & Regehr, 2013). A clear advantage of using standardized client actors (SCA) in training situations is the ability to methodically and systematically present behaviors that require intervention.
The LS training took place over the course of two days. The four stages of MI (engaging, focusing, evoking and planning) were covered with four segments of LS. Each segment followed the same format and was comprised of four main elements: 1) At the start of each day and then after lunch, the LS trainer would review MI techniques for approximately 30 minutes. 2) After each MI review, the student trainees would complete a 15-20 minute interview with a SCA (described below). Prior to each interview with the standardized client, the MI trainer would discuss a pre-session strategy with the individual trainee and small group (the five students in each LS group). The pre-session allowed the individual students to identify strategies that they intended to use in the interview and the use of basic MI skills associated with the one particular stages of MI being focused upon in that training segment 3) After each student trainee completed their standardized client interview, the LS trainer would then debrief with each student in the small group format. 4) Lastly, at the end of each segment (4 total segments over the 2 days, 2 per day), the SCA would join the small group and process her experience as a child welfare client actor and give specific feedback to the student trainees on the use and impact of MI techniques.
The LS was implemented by five field instructors trained in MI, and assisted by five additional field instructors (10 trainers total, 2 in each small group). All field instructors who participated in LS were the actual field instructors for the students in the small groups and had experience and expertise in public child welfare. The training for the LS facilitators was standardized and all trainers completed a two-year small group intensive training in order to become a trainer. The training focused on learning MI skills and how to use MI in the LS training. All field instructors were employed by the University (not volunteer field instructors).
Each of the SCAs in the RCT went through approximately three hours of training prior to interacting with the MSW students in the LS. The five SCAs, all female, were trained using identical scripts that included the history and current psychosocial functioning of the child welfare client they were portraying. Their training included information of the RCT study and detailed information about the character the SCA was portraying including mannerisms as well as affect and mood.
Child Welfare Context
Participants in this study are full-time Master’s level social work students who were enrolled in a public child welfare agency for field placement during the 2013-2014 academic year and participated in the 2013 RCT. Twenty five students participated in LS training. Students were placed in one of six public child welfare agencies. Student field placements within each child welfare agency varied with a range of placements that included permanency, family reunification, child protection services, alternative response, or prevention services.
Purpose of Current Study
The purpose of the current study was to explore the experiences and long-term takeaways of students who participated in the LS component of the 2013 RCT study and to understand how they transferred and used the MI skills learned in live supervision to their field settings with exploration of the role of the field instructor. Within the framework of adult learning, it is expected that practicing within the field practicum model would allow for the transfer of training through experiential learning. Given that MI is an EBP with specific skills and techniques, it was hypothesized that ongoing supervision with field instructors would allow for maintenance or retention of MI skills over time as well as transfer to the student’s field practice. Three questions were asked that were specific to the LS training: 1) What was your experience with the MI LS training?; 2) How often are you using MI skills in your field internship? (prompts were to ask about specific MI skills such as the OARs and MI stages); 3) How have you maintained using MI since the training? (prompts, did your field instructor encourage MI usage in the field internship?; Did your field instructor follow-up on the LS training with instruction on specific MI concepts or skills?).
Twenty of the 25 eligible students who had received the MI training with LS and SCA participated in the current study (80% of all LS students were included in the focus groups). The majority of participants were female (90%, n = 18). Participants identified as either White/Caucasian (65%, n = 13) or Black/African (35%, n = 7). The average age for focus group participants was 28.3 (SD = 6).
After receiving University Institutional Review Board approval, eligible MSW students were invited to participate in focus groups at the end of their academic year, approximately seven to eight months post their participating in LS. Six focus groups were held at the student’s child welfare field placement. Between three to five students attended each focus group. Focus groups lasted approximately 90 minutes and were facilitated by the first author and one research staff. No field instructors were present. Focus groups were audiotaped with permission and transcribed verbatim by a graduate student. Lunch was provided at the start of each focus group.
Following recommendations from several authors (Krueger, 1988; Krueger & Casey, 2009; & Padgett, 2004), qualitative analyses were used over a four step process. First, all focus groups were transcribed and uploaded into NVivo 10.0 qualitative data analysis software. Second, data were analyzed using open coding techniques. Transcripts were read line by line and then coded for common themes. Memos and notes taken during the focus groups were used to help bring clarity to the themes. Third, axial coding was used to create categories and identify patterns among the codes. And lastly, a constant comparative analysis was used to identify, compare, organize, and interpret themes.
Integrity and rigor for the qualitative research was accounted for by following recommendations for Padgett (2008). Auditing, including a detailed description of steps in the analysis as well as self-reflective notes were used to document the analysis and to be aware of any noticeable research biases. In addition, the first and second author compared coding and discussed any used transcripts and memos to discuss any disagreements among codes and themes.
Qualitative data yielded four themes that explained the student’s experience with LS and their long-term take away from the LS training. Each theme is presented below with supporting quotes from the data.
Immediate Feedback Benefits
All 20 focus group participants felt the LS training was beneficial. Students described the training as “hands on” and indicated that the immediate feedback that was given to them by the trainer and peers during their actual individual interview with the SCA, immediately after the SCA interview, and then at the end of the MI LS segment with the SCA greatly influenced their learning. By getting immediate feedback from the LS trainer during the SCA interaction, the student trainees were able to apply MI skills directly or have an interview course correction with the SCA. This live feedback improved student trainees’ understanding of MI skills and knowledge of MI as well as practical exposure in how to use MI in clinical practice. The LS allowed for the time and opportunity for students to practice their MI skills.
I’m a hands-on learner so having feedback, immediate feedback during the interview, …. definitely helped and …. then having your peers review what you’re seeing and give you suggestions, particularly, …. give me better suggestions and … explain examples, like real life examples of the impact…so that was cool.
Feedback from the SCA was seen as particularly useful. Listening to the perspective of the SCA as the child welfare client they were portraying helped students have deeper understanding of the impact of their use, or lack of use, of MI skills. Students were particularly appreciative of this, as in the field they did not have the opportunity to process their skills with actual child welfare clients.
If we did not pick up on something with the client [during the interview] but then the actors came and talked to us and it like all made sense and then we were like “oh that’s why that wasn’t working” and “that’s why that was working.”
A second beneficial aspect to the immediate feedback was the LS trainers’ ability to “break down MI.” Prior to the 2 day LS training, students had attended a one-day dyadic training where they were given basic instruction of MI. The LS training gave more specific instruction as to how and why MI should or could be used in the clinical interview.
The individual steps and practice, and then come back, and learn the next step, and then practice, and then come back…that was really helpful as far as learning it, because you could um, with the one-day training we learned the skills by reading them and understanding them and then seeing examples but I don’t think we got a chance to practice it and then have feedback, … so I think that was really helpful as far as instruction.
Use of MI in the Field
Many students reported that the OARS skills (open ended questions, affirmations, reflections, and summaries) of MI stayed with them the most after the training. Several students commented that they could “hear the person in your ear like a year afterwards” [referencing to the LS training]. The main tenets of the LS training, which students indicated were the OARS stayed with them seven months after the training. As one student stated, “when you’re out in the field, it just kind of always comes back to you.” Regarding the MI stages, students were only able to indicate they use the engaging stage from MI in their field internship (the first stage of MI). As one student described, “we just started to get to know our clients in September, so, it’s just been helpful to build, you know, build rapport with them and just get them to start telling us their story.”
Several students appeared to be motivated to use MI in the field internship and had used MI during their client interactions after their LS training. As one student stated, “at first it was difficult to use because I wasn’t used to it. But once you do it a lot [in field] it just comes natural.” Many students practiced MI in their field internships. Students who practiced these skills did so on their own, meaning when they were having interactions with child welfare clients as part of their field internship, they purposefully used MI skills. Students who were practicing MI saw the efficacy of MI with regard to ambivalence or targeted behavior change. Practicing MI skills in their field gave them confidence to use the skills. As one student described,
I did an interview [as a CPS worker] with a mom whose husband had just assaulted her, right in front her children and assaulted the kids as well and had just left the house, … and she kind of came in the office [child welfare office] and was going back and forth about whether or not she should go get a protective order or not because he could lose his job and how are they going to pay the mortgage, but you know, she’s sick of him, beating up on her, and so I kind of just sat there and I didn’t really say anything, I just kind of reflected a lot of the stuff she said and the ambivalence and I could feel myself and I was like “oh this is MI!” And I was excited and then in the end she went and got the protective order and by the end of the interview, she started off like 50/50 and then by the end [of the interview] she was like “ok this what I’m going to do” and she left from there and went and did it.
Struggle to Use MI in Child Welfare
Overall, the majority of students felt that there were barriers to using MI in child welfare. While they believed in the utility of MI and that MI could be used effectively, they struggled to find opportunities to use in MI in their child welfare field placements. Time, specific to child welfare cases, was seen as a barrier. As one student indicated, “And you may be in a situation with the family where you don’t have time to play with someone’s ambivalence for weeks on end…you might have to do something right then.” Often the contact between a child welfare worker (or MSW intern) is productive in terms of child welfare related areas that need to be addressed (i.e., permanency plans, planning for court, etc.). Other students struggled with the difference between being a child welfare worker and being a therapist.
I feel like if you put it in perspective of like child welfare versus say therapy, you know, if you’re providing…therapy, you know, your purpose there is to elicit all of this and to have the time set aside to specifically do this, that’s what your job is. And in child welfare and I can only talk for us really and specifically permanency [in the permanency unit], our job isn’t necessarily, I mean it is, we make sure they’re doing well, mentally and physically and emotionally, and all those things, but our, we have so many procedures and things in place that we need to go down our checklist and I think …, you’re blunt and to the point and if a parent’s not doing what they’re supposed to do, their kid’s going to get taken away from them or they’re not getting their kid back. So there’s so many things that are so strict and forward because we’re talking about children’s safety…that you don’t have that opportunity [to use MI] as much.
However, other students reported they were using MI “a lot” and, in particular, indicated MI was most useful when working with parents and teens. Both of these child welfare populations frequently have a target change behavior or ambivalence and students were able to recognize this and apply their MI skills, along with strictly to child welfare mandates. Students who were using MI in their field practice appeared to be both more supportive of and more confident of using MI in child welfare.
I think identifying when it’s applicable is really important. And because you’re not always going to be in situation when you’re going to be able to use MI. But when you find that part – when a client is very resistant to whatever it is that they’re resisting, it’s really important to focus on that and use MI to get through some of that resistance because that’s how we empower people to change.
Support in Using MI Post Training
All students reported that they felt an overall support of using MI in their child welfare placements. While students were given intense support during the LS training from field instructors, the intensity of support varied between individual field instructors at different agency settings and even within the same field instructor in the seven months post LS training. In addition, with some exception, most field instructors did not specifically follow-up on the LS training. For example, students were asked if they had specific follow-up lessons or tasks related to the MI training. The majority of students did not have any specific follow-up. Students have one-on-one supervision with their field instructors at minimum of once a week. However, in practice, they have supervision contact almost daily during the MSW student’s field hours. Field instructors who appeared to support ongoing use of MI often started supervision sessions by asking about the MSW student’s use of MI in their field. These supervisors would explore with the student their use of MI, possible missed chances for MI, and would intensely review process recordings. Other students reported that they knew MI was being modeled for them, but the field instructor would not point out when they were using it, leaving it to the student to recognize on his/her own when this was happening. It was not clear to the students whether the field instructors themselves recognized their own use of MI.
I think [student’s field instructor] she’s done this for so long that it’s just part of how she speaks. So when she’s gone out on visits with me in particular and I’ve seen her interact with the clients, you can see that she’s using it. But it’s not identified as “in this situation, I used MI to do this, this, and this.”
Summary of Findings
Overall, students reported that the LS training was beneficial and in particular they enjoyed the immediate feedback that was given by the LS trainer and the SCA. This feedback assisted with understanding how to apply MI in a clinical interview setting. Students expressed that their main take away from the training (seven-eight months post the training) was use of the OARS. They struggled to use more advanced components of the MI, such as the stages. However, this appeared to be mitigated by student motivation. Students who were more motivated to use MI and thus sought out interactions with their field placement child welfare clients had more confidence in their MI skills and usage in the field. Despite student motivation, most students felt there were barriers to using MI in child welfare and most frequently indicated time and time constraints for child welfare related activities (e.g., court) as barriers. Student’s perceived that field instructor support of using MI in child welfare and following-up on skills learned fluctuated during the seven-eight months post LS training. Most students indicated their field instructor did not have specific follow-up skills or tasks related to MI, post the LS training.
Limitations and Strengths
There are several limitations that must be considered when interpreting findings from this study. In focus groups, it is possible that social desirability and group conformity played a role and individual students did not feel comfortable expressing a viewpoint if it differed from others in the group. Also, 20% of the students did not participate which did limit the generalizability of the data. However, with six focus groups, the common themes emerging also provided support of the trustworthiness of the available data. For the current study, mixed methodology would have been more helpful to determine specifically how the LS students were using MI in practice and how the field instructors were using MI in supervision or encouraging the students to use MI in field. For example, triangulation of data, using a survey assessing student use of MI in the field and in focus groups would have been helpful in determining transfer of learning. Similarly, assessing field instructor use of MI in supervision through mixed methods would have added more context to study findings. In addition, student’s perceived barriers to using MI in their child welfare field placement. However, the specifics of these barriers was not assessed. For example, it is possible that students placed in different child welfare units (e.g., adoptions, foster care, child protective services) may have perceived different opportunities to use MI.
The goals of this study were to investigate student experiences with and their maintenance of MI, an EBP that was learned through LS, and to assess the role of the field instructor. The LS training was successful in terms of teaching MSW students basic MI skills and encouraging students to acknowledge MI as a useful approach for child welfare. The majority of students endorsed using MI skills seven months post the LS training. However, they endorsed using the OARS, basic MI skills for engaging, but reported having difficulty using more advanced skills to move clients into later stages of MI practice, such as evoking change talk.
Baldwin and Ford (1988) suggest that conditions for transfer of learning should include generalizing the material to the job context and maintaining the learned material over a period of time. MSW students sought and relied on their field instructor for guidance on how to translate the skills of MI to practice. Field instructors were tasked with providing field instruction that included helping the MSW student navigate the child welfare agency and adhere to child welfare based timelines that include timely tasks and court reports, as well as instructing on clinical practice skills needed for the child welfare population (i.e., individuals with substance abuse challenges or daily living needs such as housing and food), and training on MI. While the LS training was excellently developed and implemented, a formal follow-up for students to maintain what was learned through LS was not planned. The lack of integration of MI in field instruction was not due to a lack of knowledge on the part of the field instructor, but is reflective of other barriers to the integration of knowledge into field instruction. All field instructors had been trained in MI and were using MI in their own practice and with their MSW students. However, there was not any formal plan for field instructors to follow-up on the MI LS training and it is possible, given the heavy agenda of field instruction, field instructors may not have given LS formal attention over the course of the students’ field placement experience.
Following adult learning assumptions posited by Knowles et al. (2015), the students in the LS training did indeed appear to have both the desire and motivation to learn. The LS learning experience was directly relevant to their field placement and some students were self-directed learners by purposefully planning to use MI in their field interactions. In addition, the LS allowed for real time feedback from the LS trainer and timely feedback from the SCA; both were experiential learning elements that added to the student’s mastering of MI. However, transfer of learning for the MI LS training was not included in the original intervention. Maintenance of skills learned was not specifically addressed during field instruction or field experiences (with the field instructor). The results also provide support to other prior theories of adult learning. Daffron and North (2011) and Baldwin and Ford (1998) discuss work environment as a necessary component of successful learning. In this case, child welfare social work students were practicing within a larger work culture and environment which included the need to practice within conflicting demands and timelines that were imposed by outside systems (i.e., court orders from criminal justice organizations). Such a work environment did not seem to fully embrace the use of MI as an approach. Organizational barriers and systematic factors were reported by the students as minimizing their opportunity to practice the skills they learned.
Implications for Social Work
Findings from this study have direct application to field instruction. Learning is transformative and has the potential to lead to personal growth (Chen, 2014). The LS training was expertly developed and implemented and indeed students learned from the training and reported using MI in their field practice. However, without having a specific follow-up plan that included field instruction, MSW students were not able to maintain advanced skills learned or transfer the more important theoretical components, such as the later stages of MI, of the training. These advanced skills needed more practice which continual supervision would have made possible. The importance of the field instructor in following-up on MI skills with their student and addressing all other needs of field supervision was overlooked in planning for the LS. However, what social work educators also need to explore is the time constraints and responsibilities that field instructors have, and plan accordingly to make continual supervision possible, and not an added burden.
This study was supported by a University of Maryland School of Social Work Competitive Innovative Research Award.
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