Table 1 Description of the educational intervention using the GREET

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THEORY

This educational intervention was developed according to the ECHO model [39, 40], which is rooted in three established social, learning theories: 1) Bandura’s Social Cognitive Theory [41]; 2) Lave and Wenger’s Situated Learning Theory [42]; and 3) Wenger’s Theory of Communities of Practice [43].

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LEARNING OBJECTIVES

The educational intervention embraced three distinct learning objectives: 1) to enhance participants’ knowledge in CD EBP; 2) to amplify participants’ competencies in addressing CDs and facing complexity; and 3) to build a learning community in which healthcare professionals can receive support in working with challenging situations of patients with CDs.

The educational intervention also included specific learning objectives based on the case-based discussion and the didactic presentations for each session of a given curriculum. These learning objectives were developed to match the NICE 2016 guidelines on CD care [11]. Specific learning objectives were applicable to all professional groups. An example of the specific learning objectives for the 2018–2019 curriculum can be found in the study protocol published elsewhere [35].

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EBP CONTENT

Each session included a didactic presentation that consisted of a specific CD EBP topic. The topics covered mental health and psychiatric issues (e.g., psychotic disorders, anxiety disorders, eating disorders), addiction care and treatment (e.g., opioid use disorder, withdrawal management), co-occurring medical issues (e.g., HCV), as well as other psychosocial topics (e.g., homelessness, legal and ethical issues, referral pathways). It also included broader CD-related topics, such as basics in integrated care treatment, core values, attitude, and relational skills, and planning and coordinating care between healthcare professionals, teams, and agencies.

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MATERIALS

Materials provided to learners:

- At the time of their registration, participants were provided with an electronic document explaining the educational intervention’s purpose, the sessions’ structure and functioning, and the learning objectives and activities.

- One week prior to each session, an electronic document detailing the clinical situation to be discussed was emailed to all participants. This document has predetermined sections, which were filled out by the healthcare professionals presenting the clinical situation (i.e., patient case).

- Didactic presentations were supported with a PowerPoint presentation and shared with participants via email after each session.

- The programme has its own website, which offers several CD resources that participants can consult at any time.

- A scientific librarian emailed scientific articles and clinical tools related to CDs each month.

- A written summary combining recommendations and guidance from the team of experts was sent to healthcare professionals (or team of healthcare professionals) who had presented a clinical situation. This electronic document generally consisted of interventions to add to their patients’ care plan.

Materials used for instructors: A paper-version document that details the ECHO model learning principles (i.e., learning methods and educational strategies) was given to each member of the team of experts as guidance on EBP teaching methods. This document also included a step-by-step approach on how to replicate the ECHO model in other contexts.

VC equipment: To run a session online, the team of experts used a Logtech Group ConferenceCam kit that is connected to a Lenovo Windows PC with two 55″ screen mounted on a support. In this study, nurses were able to join videoconference sessions via a desktop or laptop computer, phone, tablet or any other mobile device. Nurses were equipped by their employer for the minimum technical equipment required to run a videoconference session online (i.e., desktop or laptop computer, internet connection, speakers, and microphones). However, some nurses did not have access to a webcam or HD cam.

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EDUCATIONAL STRATEGIES

During each session, the following three educational strategies were used, concurrently:

- Case-based discussion: For each session, a clinical situation was chosen by a healthcare professional (or team of healthcare professionals), and then presented to all participants. Prior to the session, the healthcare professional was asked to prepare a summary of the clinical situation by detailing the patient’s biopsychosocial needs, and by identifying questions for the group to consider about that clinical situation. Following that, a discussion period allowed for questions, reflections, and sharing of knowledge and personal experiences. Lastly, recommendations and guidance from the team of experts and participants were provided verbally during the session and then in a written summary to the healthcare professional (or team of healthcare professionals) who presented the clinical situation.

- Traditional lecture: Didactic presentations about CD EBP.

- Reflective practice: In the weeks to months after the case-based discussion, some participants were asked to present the chosen clinical situation again. During this follow-up discussion, the implementation and the impact of the recommendations provided during the previous session were reviewed and assessed. Participants also had the opportunity to complete an online test of their CD CDs every six months. This provided them with feedback from the team of experts on their learning needs.

In this qualitative study, research interviews with nurses allowed them to reflect on their learning progress during their ECHO-CD participation, and how it contributed to their clinical practice.

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INCENTIVES

Continuing education credits were given to participants after each completed session.

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INSTRUCTORS

Instructors: The team of experts included psychiatrists, physicians with a specialization in substance-use disorders, registered nurses and a clinical nurse specialist, pharmacists, social workers, psychologists, occupational therapists, and a scientific librarian.

Other professionals included in the intervention:

- In case of a specific medical issue, specialists from the quaternary hospital centre were invited to join the team of experts for further guidance (e.g., hepatologist, physician with expertise in HIV treatment).

- Each session, a project manager assisted the team of experts to mediate the participants’ interactions. This involved answering the participants’ questions in the forum’s app and ensuring that each participant had the opportunity to ask questions or share their knowledge, experience, and/or ideas.

- Additionally, a computer scientist offered in-person support during each session to resolve any technical issues that could arise during the session.

Experience and expertise: All healthcare professionals from the team of experts had expertise in CDs or at least six months of experience in working with CD patients. Registered nurses from the expert team had at least a bachelor’s degree and at least six months of clinical experience in CD care. According to their discipline, the healthcare professionals on the expert team had different specializations such as motivational interviewing, relapse prevention, cognitive and behavioural therapy, working with vulnerable populations (e.g., youth, homeless people, pregnant women), Hepatitis C treatment and treatment for opioids use disorders.

Roles:

- Facilitator: During each session, the same psychiatrist on the expert team acted as a facilitator. This role consisted of introducing each member of the expert team, making sure that all participants had time to introduce themselves, summarizing expert and peer recommendations at the end of a session, and ensuring that the session went smoothly and that the schedule was followed. The facilitator also provided feedback to participants throughout the sessions.

- Team of experts: Healthcare professionals from the team of experts are invited to ask questions regarding the clinical situation for further information and/or clarifications. They also provide recommendations and/or feedback during the course of a given session, according to their own discipline and area of expertise. At each session, a healthcare professional from the team of experts delivered a didactic presentation on CD EBP.

Training related to the educational intervention provided to instructors: As part of a requirement for ECHO-affiliated programmes, two healthcare professionals from the team of experts attended a four-day immersion training by the ECHO Ontario Mental Health (ECHO-OMH) programme at the Centre for Addictions and Mental Health (CAMH) in the province of Toronto, Canada [32]. The goal of the immersion training was to offer guidance on how to replicate the ECHO model in other contexts and to ensure that replicated ECHO programmes are delivered according to the highest standards of continuing education. Training on learning methods, teaching strategies, and core pedagogical skills was provided during this immersion. The immersion training session was originally developed at the ECHO Institute in the state of New Mexico, US, to ensure fidelity between the ECHO model and future replications.

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DELIVERY

Modes of delivery: The educational intervention was exclusively provided online through simultaneous videoconference sessions. Learning activities were held as a group.

Ratio: There were no formal limits on the number of online participants for each session. Each curriculum had up to 200 registrants, with an average of 50 to 60 participants connected at any one time, and a minimum of four experts with different interdisciplinary backgrounds to ensure that recommendations were tailored to a wide range of professional groups.

Sequence of learning activities: Each curriculum included an orientation session to familiarize participants with the educational intervention’s structure and learning objectives, and the videoconference technology. Then, each subsequent session had five main learning activities, which took place into the following sequence: 1) a 10-minute introduction, in which the team of experts and the participants introduced themselves; 2) a presentation about a clinical situation (15 minutes); 3) a discussion period regarding the clinical situation (30 minutes); 4) a period for clinical guidance and recommendations (15 minutes); and 5) a didactic presentation, including a lecture and questions (20 minutes).

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ENVIRONMENT

Location: The team of experts (the “Hub”) delivered the educational intervention from a conference room in the quaternary academic hospital centre, located in the province of Quebec, Canada. Participating health care professionals (the “Spokes”) were located in different urban and rural areas across the province and joined the sessions from their workplace or home.

Technical environment: The Zoom platform.

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SCHEDULE

Number of sessions: Each curriculum included 20 sessions from September to June. Participants had the opportunity to register for more than one cycle.

Frequency: Every two weeks.

Timing and duration: 90 minutes, from 12:00 p.m. to 1:30 p.m.

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FACE-TO-FACE CONTACT WITH INSTRUCTORS AND/OR SELF-DIRECTED LEARNING ACTIVITIES

Each session consisted of virtual face-to-face contact between the team of experts and other participants. Self-directed activities consisted of clinical guidance, tailored recommendations, and feedback.

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SPECIFIC ADAPTATION FOR THE LEARNERS

The content of the educational intervention was adapted to the participants’ needs as follows:

- In order to adapt content to participants’ requests and learning needs, no specific topics were planned for the last two didactic presentations of each curriculum. The topics of these two didactic presentations were chosen based on the participants’ responses in the after-session feedback questionnaires.

- If a specific health issue generated questions, a scientific librarian provided participants with further resources and/or information during or after the session.

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MODIFICATIONS MADE TO THE EDUCATIONAL INTERVENTION DURING THE COURSE OF THE STUDY

During the COVID-19 pandemic, the following modifications were made to the 2019–2020 curriculum:

- Content: Two didactic presentations on COVID-19 were developed and later presented to participants (i.e., management of CDs and COVID-19 during hospitalization, and issues related to people with substance use disorders and COVID-19).

- Environment: Healthcare professionals from the team of experts attended the sessions in separate rooms instead of being grouped in a larger conference room.

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ATTENDANCE

Participation in each session was not mandatory. However, the frequency of nurses’ session attendance was tracked as part of a larger mixed methods research project [35].

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PROCESSESS TO DETERMINE WETHER THE MATERIALS (item 5) AND EDUCATIONAL STRATEGIES (item 6) WERE DELIVERED AS PLANNED

In this qualitative study, nurses were invited to describe their experiences and perceptions regarding the educational intervention and to reflect on their own learning during individual semi-structured interviews. Also, an ECHO-CD Committee was implemented at the quaternary academic health centre for continuing programme improvement. Within this committee, healthcare professionals who participated in the first two cycles of ECHO-CD were invited to provide feedback and suggestions. These were later used to adapt the programme to their learning needs and local realities.

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EXTENT TO WHICH THE EDUCATIONAL INTERVENTION WAS DELIVERED AS SCHEDULE

Both curricula (i.e., 2018–2019 and 2019–2020) were delivered as scheduled.