The Impact of COVID-19 in Reshaping Graduate Medical Education: Harnessing Hybrid Learning and Virtual Training.

Introduction  At the start of the COVID-19 pandemic, many graduate medical education (GME) programs switched from in-person to virtual training to ensure a safe learning environment. However, the preferences of US residents in the wake of the COVID-19 pandemic are largely unknown. Objective The authors surveyed PGY-2 psychiatry residents about their perception of the pandemic's impact on their clinical skills, didactics experience, training preferences, and future career perceptions. Methods The cross-sectional study was conducted from October 31, 2021, to December 31, 2021. The authors emailed a survey to directors of US general psychiatry residency programs to disseminate to PGY-2 residents. The survey had Likert-scale and open-ended questions about the pandemic's perceived impact on PGY-1 training and future training preferences. The authors used descriptive statistics for Likert-scale questions and reflexive thematic analysis for open-ended questions. Results Out of an estimated 1800 residents, only 116 (6.4%) participated; post-pandemic preferences emerged. A strong preference was expressed for hybrid didactics, combining in-person and virtual learning. Virtual patient evaluations, especially in emergency and inpatient settings, were highly valued. Conversely, entirely virtual didactics and clinical rounds were deemed least preferred, emphasizing the importance of interactive, hands-on learning experiences. Conclusions Respondents emphasized the significance of incorporating hybrid models for both in-patient care and didactic sessions in GME. These preferences signify the need for adaptable and flexible approaches to education in psychiatry residency programs as we emerge from the pandemic.

Veterans Administration Readjustment Counseling Service Counselors' Training Needs: Results of a National Needs Assessment.

The Department of Veteran Affairs established Readjustment Counseling Service (RCS) to meet the mental health needs of active-duty service members, veterans, and their families. A diverse therapeutic skill set is needed to serve this complex population. To assess training needs, a national mixed-methods needs assessment consisting of a survey for RCS counselors and focus groups among counselors, RCS educational trainers, and national leadership was conducted. Survey results (n = 681) showed that RCS counselors were most interested in trainings on moral injury, acceptance and commitment therapy, and military sexual trauma (MST). Desired trainings aligned with populations served. Themes from focus groups revealed the need for foundational trainings so that all RCS counselors are adept in treating MST, moral injury, and posttraumatic disorder and proficient in caring for couples. Additionally, counselors desired advanced trainings tailored to individual counselors' needs. RCS counselors identified multiple trainings to help them treat those they serve.

Making an Impact: Evaluation of an Enduring Online Training Empowering Clinicians to Respond to Hate Speech.

Mental health clinicians frequently experience hate speech during patient care, resulting in an ethical dilemma. This study evaluated a 1-hour webinar discussing the ethics of working with Veterans who use hate speech, motivations and intentions of hate speech, and guidance on how to respond. The webinar was offered through the virtual Community-Based Outpatient Clinic Mental Health Grand Rounds session at the Veterans Health Administration (VHA). Rural mental health clinicians were the target audience; however, all VHA clinicians could attend. Participants were VHA clinicians who completed the evaluation for the training and received one continuing education unit for this training (n = 668). They were highly satisfied with the training and would recommend it to others. They also reported the intention to talk with coworkers and trainees about responding to hate speech and requested additional training. The recorded training can be viewed for free at https://www.mirecc.va.gov/visn16/working-with-patients-who-use-hate-speech.asp.

Narrowing the Treatment Gap: A Call to Increase Use of Direct-to-Consumer Marketing in Psychotherapy Practice and Research.

A mental health treatment gap exists in which individuals who would benefit from evidence-based psychotherapies (EBPs) do not receive them. It is critical to take effective actions so that individuals with unmet mental health needs feel empowered to seek treatment. Direct-to-consumer (DTC) marketing meets this objective. DTC marketing is an effective, patient-centered approach that creates patient demand for a product or service by influencing patient behaviors, attitudes, and preferences. While primarily used in the United States and New Zealand to promote prescription drugs, uses and practices for DTC marketing with nonpharmaceutical EBPs are less established. This article highlights the value of leveraging this marketing approach to increase awareness and use of EBPs. Additionally, an illustrative example is presented that describes the use of social marketing and marketing mix principles to develop effective DTC marketing campaigns in psychotherapy practice.

Feasibility of Group-Based Implementation Facilitation for Video Telemental Health.

Video telehealth experienced rapid growth throughout the COVID-19 pandemic in many healthcare sectors, including mental health. The Veterans Health Administration's video telehealth platform, VA Video Connect, has been widely used to reach veterans who may have experienced difficulty accessing care, such as those living in rural areas or other barriers (e.g., transportation). Implementing VVC requires a multifaceted approach, including training providers on technical skills, increasing access to equipment for providers and veterans, and integrating VVC within the culture and processes of the clinic unit. Prior successful VVC implementation efforts in rural areas have focused on simultaneous one-on-one provider and leadership engagement using implementation facilitation (IF). However, given the rapid need for VVC expansion in light of limits and dangers associated with in-person care during the pandemic, our team developed group facilitation to increase the reach of VVC implementation through IF. Group facilitation combined training in technical and policy elements of VVC with IF with groups of providers from clinic units. This approach was designed to rapidly disseminate the necessary knowledge to conduct VVC combined with collaborative problem solving as a team to improve the ability of the clinical team to sustain VVC. Attendees were asked for feedback on the session through multiple choice and open-ended questions. Participants (N = 26) reported being highly satisfied with the training and reported a high degree of confidence in their ability to use VVC. Based on evaluation data and interview feedback, providers and clinic leaders were satisfied with group facilitation. Group facilitation may be a helpful tool in rapidly training clinical teams to implement and sustain video telemental health.

Advances in Psychotherapy for Older Adults Using Video-to-Home Treatment.

Providing telemental health services to older adults has become especially important during the COVID-19 pandemic. Video-to-home (VTH) treatment is an effective treatment modality; research shows that older adults are open to using VTH. However, there are unique barriers to using VTH with older adults. Barriers include access to technology, acceptance of technology, and physical and cognitive limitations. Additional concerns include establishing rapport with older patients and the policy and ethical concerns surrounding the use of VTH. Methods of addressing these barriers have been developed, and more research is needed to develop evidence-based VTH practice.

A Scoping Review of Recommendations and Training to Respond to Patient Microaggressions.

OBJECTIVE: Patient microaggressions affect practitioners in all fields of healthcare and especially psychiatry. In multiple studies, healthcare professionals reported high rates of patient microaggressions and discrimination. To date, this is the first scoping review of recommendations and trainings on patient microaggressions. METHOD: A scoping review of articles indexed in PubMed, PsycINFO, Medline, ERIC, and MedEdPORTAL was conducted from July 2020 to August 2020 to identify recommendations and solutions for healthcare professionals on responding to patient microaggressions. RESULTS: The review identified 27 studies that provide recommendations and trainings for healthcare professionals to address patient microaggressions. Twenty studies outlined recommendations for healthcare professionals and systems on how to respond to patient offenses. These 20 studies were grouped into establishing a supportive culture, addressing the microaggression, supporting the targets of microaggressions, discriminatory requests, and institutional responses. Six articles described trainings that equip providers with tools to address patient microaggressions, including the ERASE framework ("Expect/Recognize/Address/Support/Establish, Encourage"); Stop, Talk, and Roll; interrupting microaggressions; XYZ ("I felt X when Y because Z"); the ACTION model ("Ask/Come/Tell/Impact/Own/Next"); and the OWTFD tool ("Observe/Why/Think/Feel/Desire"). CONCLUSION: Recommendations and trainings for the response to microaggressions are emerging, and results of trainings are encouraging. However, more work is needed to evaluate the effectiveness of these trainings in clinical settings and longitudinally.

A high-need, high-impact educational session on firearms and death by suicide.

BACKGROUND: The suicide rate among Veterans is 1.5 times greater than that for civilians, partly a result of the high use of firearms as the means for suicide. One effective strategy to reduce Veteran suicide by firearms is to provide counseling on firearm safety as a method of means reduction. However, many clinicians do not discuss firearm safety with Veterans. AIMS: This study evaluates a one-hour educational seminar for clinicians on lethal means safety. MATERIALS AND METHODS: One hundred and ninety clinicians from the Veterans Health Administration, including social workers, psychologists, psychiatrists, and nurses, participated in the training. The seminar was streamed during the South Central Mental Health Illness Research, Education and Clinical Center's Community-Based Outpatient Clinic Mental Health Grand Rounds, for which participants were eligible for continuing education units. Data were collected immediately after the training and four months later. RESULTS: After completing the training, participants believed that it was important to speak with Veterans about firearm safety and felt knowledgeable and empowered to do so. Four months after the seminar, participants had counseled, on average, over half of Veterans treated about lethal means safety. DISCUSSION: Participants reported the value of normalizing discussions about firearm safety with their Veterans and focusing on the safety aspect while discussing firearms. CONCLUSIONS: This webinar was effective in providing clinicians the skills to talk with Veterans about firearm safety and continued to impact their practice four months after training. The training is available for free on our website at https://www.mirecc.va.gov/visn16/public-health-approach-to-firearms-and-death-by-suicide.asp.

Virtual Synchronous Motivational Interviewing Training for Geographically Dispersed Interprofessional Learners.

INTRODUCTION: Behavioral health and other preventable factors account for nearly half of all premature deaths in the United States. Motivational interviewing (MI) is effective for engaging ambivalent patients in behavior change. However, many clinicians report barriers to receiving MI training, including time, cost, and travel. This study examined the effect of a 2-day virtual MI training built around didactic and real-play learning activities. METHODS: Thirty interprofessional clinicians from eight Veterans Affairs medical centers and their community-based outpatient clinics across 4 US states attended a 2-day virtual MI training. Participants completed a posttraining evaluation and a 3-month posttraining evaluation. RESULTS: Participants reported that they learned new knowledge and skills, and they would be able to apply these to their practice (M > 4).They reported high satisfaction with the training and platform and found the technology easy to use (M > 4). In the 3-month posttraining survey, participants reported that they were using MI in their practice (M = 4.19) and that they would like additional support, such as additional reading (n = 8). DISCUSSION: This study demonstrates the effect of a 2-day virtual MI training built around didactic and real-play learning activities. Virtual training particularly enhances training opportunities in rural settings. Our training removed travel and payment as barriers to participation.

Cannabis use disorder and post-traumatic stress disorder: The prevalence of comorbidity in veterans of recent conflicts.

AIMS: Veterans have high rates of cannabis use, and rates of cannabis use disorder (CUD) are rising among this population. These rising rates are particularly true for veterans with post-traumatic stress disorder (PTSD), which is common among veterans of recent conflicts, Operations Enduring Freedom, Iraqi Freedom, and Operation New Dawn (OEF/OIF/OND). Although prior work has documented links between PTSD and cannabis use, a better understanding of the intersection among CUD, PTSD, and other disorders in real-world clinical practice can inform prevention and treatment efforts. This study examined the prevalence and comorbidities of CUD and PTSD in OFE/OIF/OND veterans. METHOD: The study analyzed data from the Veterans Affairs Corporate Data Warehouse (2010-2016) for returning war veterans who were diagnosed with CUD (N = 46,268). The study determined prevalence of PTSD, and examined additional differences in comorbidities. RESULTS: The prevalence of a comorbid PTSD diagnosis among OEF/OIF/OND veterans with a CUD diagnosis was 72.3%. Further analysis revealed additional co-occurring disorders. Veterans with a diagnosis of CUD and PTSD were more likely to have a comorbid diagnosis of depression (odds ratio, 1.69; 95% CI, 1.62-1.71), panic disorder (odds ratio; 1.58; 95% CI, 1.43-1.75), alcohol use disorder (odds ratio; 1.30; 95% CI, 1.24-1.35), opioid use disorder (odds ratio; 1.52; 95% CI, 1.43-1.62), and insomnia (odds ratio; 1.74; 95% CI, 1.65-1.84) than veterans without a PTSD diagnosis. CONCLUSIONS: Findings highlight that the majority of returning war veterans with CUD are highly complex. Our findings substantiate the need for urgent, comprehensive care for veterans with co-occurring CUD and PTSD, including integrated and transdiagnostic treatment approaches.

Wellness for Warriors: Developing and Disseminating a Veteran-centric Wellness Guide.

BACKGROUND: Evidence-based self-help wellness interventions have several benefits, including low cost, brevity, and lack of need for a health care professional. Veterans, in particular, may benefit from a self-guided resource, given a culture of self-reliance, mental health help-seeking stigma, and a high need for mental health care. Despite the high need, few self-help resources are designed for veterans. OBJECTIVES: The goal of this project was to create the Veteran Wellness Guide, a self-guided resource comprising SMART goal setting and evidence-based interventions for veterans (e.g., self-kindness, gratitude, diaphragmatic breathing, mindfulness). METHODS: First, a Veteran Engagement Group reviewed the guide and provided feedback on veteran-centric content and design. After the authors revised the guide, a subset of the group approved changes. Additional veterans used it for 2 weeks and provided feedback. RESULTS: Veterans reported the guide as being highly useful, were willing to recommend it to other veterans, and identified a need for it in the veteran community. Veterans and Veterans Health Administration clinicians and leadership helped to craft a dissemination plan to reach veterans whether they receive care through the Veterans Health Administration or the community. CONCLUSIONS: Partnering with veterans in the creation of the wellness guide led to a veteran-centric product tailored to meet the unique wellness needs of veterans. The guide has been nationally disseminated and downloaded over 3000 times and can be downloaded for free from our website.

Development of a Hybrid, Interprofessional, Interactive Quality Improvement Curriculum as a Model for Continuing Professional Development.

Over the past 20 years, there has been an increased focus on quality improvement (QI) in health care, which is critical in achieving care that is patient-centered, safer, timelier, and more effective, efficient, and equitable. At the center of this movement is QI education, which is known to lead to learning, behavior change, and improved outcomes. However, there is a need for the development and provision of long-duration, interactive, interprofessional training in QI, to allow for in-depth learning and application of learned skills. To this end, we designed a curriculum for an established interprofessional, interactive, web-based QI fellowship for doctorally prepared clinicians. Curricular content is delivered virtually to geographically dispersed learners over a 2-year time span. The didactic curriculum and experiential learning opportunities provide learners with the foundational knowledge and practical skills to engage in-and eventually, lead-QI initiatives around the country. Evaluation of learner satisfaction and cognitive, affective, and skills-based learning has found that this model is an effective method to train geographically distributed learners. A hybrid training structure is used, where learners interact with the material through 3 distinct delivery modes: (1) virtual instruction in QI topics; (2) face-to-face training, mentorship, and the opportunity for practical application of applied knowledge and skills through the completion of QI projects; and (3) opportunities for other types of training, tailored to each learner's Individual Development Plan. This training program model holds value for QI learning in various health care settings, which are interprofessional by nature. These foundational concepts of hybrid learning to distributed learners-wherein an instructor delivers curriculum in small, face-to-face batches, interprofessional learning is supplemented in a virtual, longitudinal manner, and learners are allowed the opportunity to put skills into action for real-world problems in interdisciplinary clinical teams-can be applied in a multitude of settings, with comparatively lower time and cost expenditure than traditional training programs.

Elder Abuse Education Using Standardized Patient Simulation in an Undergraduate Nursing Program.

BACKGROUND: With more than 1 million older adults being abused each year, it is imperative for nurses to be knowledgeable about signs and symptoms of elder abuse, assessment, and interventions. This article describes a three-part learning strategy consisting of lecture, simulation using standardized patients (SPs), and debriefing to educate prelicensure nursing students about how to identify, assess, and report elder abuse. Furthermore, the effects of the teaching strategies were assessed. METHOD: Students received a lecture on elder abuse, followed by a simulation with an SP and debriefing. Pre- and posttests were used to assess knowledge, skills, and attitudes about elder abuse. RESULTS: Significant differences were found in pre- and posttest results for knowledge and skills. There were no significant differences in attitude. Teaching strategies affected learning, and students reported increased knowledge and skills in identifying abuse and advocating for vulnerable older adults. CONCLUSION: Lecture and SP simulation followed by debriefing was an effective approach to educate prelicensure nursing students about elder abuse. [J Nurs Educ. 2020;59(6):331-335.].

Development and Dissemination of an Interprofessional Online Dementia Training Curriculum.

OBJECTIVES: Despite the growing number of individuals with dementia, clinicians skilled in caring for people with dementia, especially in rural areas, are lacking. The Program for Advancing Cognitive Disorders Education for Rural Staff (PACERS) was designed to improve clinician competency and comfort when caring for individuals with dementia. Based on an interprofessional needs assessment, six 1-hour training modules were created: (1) Dementia and Delirium, (2) Identifying and Assessing for Dementia, (3) Treating Dementia: Case Studies, (4) Normal Cognitive Aging and Dementia Caregiving, (5) Addressing Decision Making and Safety in Dementia, and (6) Dementia and Driving. Each module is available for free on the Department of Veterans Affairs Talent Management System (TMS) for employees and the free TrainingFinder Real-time Affiliate Integrated Network (TRAIN) platform for clinicians in the community. One continuing education unit is earned upon completion of each module. DESIGN: Posttest. SETTING: Online training at VA TMS and TRAIN. PARTICIPANTS: To date, more than 3000 modules have been completed by interprofessional healthcare learners (eg, nurses, physicians, psychologists, and social workers). MEASUREMENTS: Satisfaction, perceived utility of training, knowledge, skills, and attitudes were assessed. RESULTS: The learners reported high satisfaction (mean [M] > 4) and ability to apply the knowledge and skills learned from the module to their job (M > 4) on a Likert scale (1 = Strongly disagree to 5 = Strongly agree). CONCLUSION: Learners also reported perceived impact on both direct patient care (eg, ability to provide education and support to individuals with dementia and their caregivers) and system-level care (eg, more appropriate referrals). Given the number of users and their evaluation data, PACERS can serve as a model curriculum for online interprofessional dementia training. J Am Geriatr Soc 68:192-197, 2019.

Transforming Veterans Health Administration Mental Health Clinician Education and Practices: 20 Years of Educational Initiatives by a Center of Excellence.

Twenty years ago, the US Congress articulated a need to decrease the time it takes clinical best practices to move from the literature to daily clinical practice. The Veterans Affairs South Central Mental Illness Research, Education, and Clinical Center was one of several centers of excellence established to address this need. It is also unique in that it focuses on rural and underserved veterans. This article summarizes the education accomplishments of the South Central Mental Illness Research, Education, and Clinical Center thus far in providing educational resources and trainings to frontline Veterans Affairs mental health staff with the goal of bringing best practices to routine clinical care, thus improving mental health services. We describe the use of implementation science to support dissemination of information, such as the monthly mental health grand rounds, especially for rural staff to receive continuing education, and the adoption of evidence-based psychotherapy trainings. The Clinical Educator Grants program allows clinicians to share their clinical expertise through development of practical tools for practice gaps they identify. We describe some future directions to meet the evolving needs of Veterans Affairs and community clinicians to provide the best possible care to Veterans. Take-away messages are that, for trainings to be successful, an implementation plan is critical and that an effective educational program requires funding and leadership commitment.

Eleven Principles for Teaching Quality Improvement Virtually: Engaging With Geographically Distributed Learners.

Health care professionals in the United States are expected to engage in quality improvement (QI) as part of their daily practice. This has created the need for QI training at all levels of health professional education. A reported barrier to increasing QI-trained health care professionals is the lack of QI-trained faculty at health care institutions and the limited availability of practitioners, given their daily clinical demands. E-learning is a potential solution. E-learning allows learning outside the traditional classroom setting, where instructors can flexibly deliver practical QI curricula to an interprofessional audience in multiple practice locations. The 11 principles presented in this article are derived from established evidence and experience and provide QI educators with practical principles for course design, implementation, and learner feedback of an e-learning course in QI.

Evaluation of a Distance Learning Curriculum for Interprofessional Quality Improvement Leaders.

As health care systems move toward value-based care, training future leaders in quality improvement (QI) is essential. Web-based training allows for broad dissemination of QI knowledge to geographically distributed learners. The authors conducted a longitudinal evaluation of a structured, synchronous web-based, advanced QI curriculum that facilitated engagement and real-time feedback. Learners (n = 54) were satisfied (overall satisfaction; M = 3.31/4.00), and there were improvements in cognitive (immediate QI knowledge tests; P = .02), affective (self-efficacy of QI skills; P < .001), and skill-based learning (Quality Improvement Knowledge Application Tool; P < .001). There was significant improvement in affective transfer (interprofessional attitudes on the job; p < .01) but no significant change on cognitive (distal QI knowledge test; P = .91), or skill-based transfer (self-reported interprofessional collaboration job skills; P = .23). The findings suggest that this model can be effective to train geographically distributed future QI leaders.