Table 3 Emerging themes and sub-themes with supporting excerpts from the interview transcripts

Theme 1:

Developing competencies to use in clinical practice when encountering people with CDs

1.1 Pursuing its own professional development and further enhancing practices for CDs by using one’s learning experience

- Things we’ve seen or had access to in the ECHO programme, well, I share them. There’s also a moment in the week where my colleagues and I take the time for a little wrap-up… you add an item to the agenda to tell others about an article or whatever, something that caught our attention. That’s something we’re trying to do also now more and more So it’s not ECHO, but we do it on a small scale. (P4).

- What I appreciated was when we had to fill out the knowledge questionnaires after the session and it showed our weaknesses, the things that we had to work on and improve, like, for me it was alcohol withdrawal and suicide risk. It’s an opportunity for self-reflection. (P5).

1.2 Integrating new interventions while dealing with the complex healthcare needs of people with CDs

- What I realized is that my patients aren’t much different from other patients. So, in many cases I told myself: “Well, don’t lose hope.” There was a patient that it’s been years he’s like the same person doing the same thing the same way, but it was still worth a shot to invest in him. And I think that what I learned over the course of many ECHO sessions is that yes, it’s true, it’s difficult to take care of people with concurrent disorders, but despite everything there are still solutions and things that you can do. (P4).

1.3 Providing care to people with CDs using an integrated approach

- However, I find in fact that during ECHO … it was nonetheless at the heart of the matter to work as much on physical health, as on mental health, as on substance use disorders. I think that it was something that kept coming back at just about all the ECHO sessions, the importance to address all of the different issues at the same time. There was also a didactic presentation that talked a little about the effects of substance use on, among other things, on cognition. Being able to assess the impact of withdrawal and to adapt ultimately our interventions to the clinical situation. (P10).

1.4 Using new knowledge and skills to deliver evidence-based interventions to people with CDs

- I have the impression that since ECHO, I am more developing motivational interviewing in my practice. Of course I was already doing it, I already had some basic knowledge, but I have the impression that it’s something that’s now a little more developed. I think that I communicate it better through my practice, especially if the patient really wants to hear it, you know. (P1).

1.5 Maximizing opportunities for collaboration

- The more contact I had with addiction services’ team, the easier the communication with them, the more I know their services, the better I can then explain them to our patients and inform them adequately, in the end, on what’s available and how to access those services. (P1).

- My colleagues and I we help each other quite a bit and we form a pretty tight-knit team, so when we’re faced with challenges, well, we look for other ideas, other resources in our team. We try not to go it alone when there are complex situations. So this way we feel less overwhelmed. (P5).

1.6 Making more effective use of apposite resources by knowing what’s available

- Like it or not, it helps to do some mentoring like ECHO with various types of professionals and organizations. So that incites my team and I even more to use existing services for further information and clinical support. It opens things up. (P9).

1.7 Providing flexible follow-up tailored to the unique needs of people with CDs

- I think I am less trying to rush things up. I’m asking if the time is right for the person to quit alcohol and really take the time to patch things up properly afterwards. Sometimes it’s a matter of paving the way better, maybe take a little more time at first to prepare the person to quit for it to be more effective in the long run. (P2).

- Having the treatment plan up to date… But sometimes you don’t always have the time, so you don’t always do it. Often, it’s the first thing that falls by the wayside. But realizing that in fact, well, it’s important to question things regularly, to update them all the time. So that was highlighted during ECHO. (P4).

1.8 Adopting non-judgmental attitudes towards people with CDs to maintain therapeutic alliance

- I have the impression that I’m more understanding … much less judgmental. I imagine that it must transpire in my body language that I am not the least bit judgmental and all I really want to do is properly assess the situation and direct the person towards the proper resources, guide them properly. (P9).

Theme 2:

Learning through a shifting lens and transforming clinical practice

2.1 Developing one’s competencies through peer experience

- Me personally, I think, it’s really a matter of give and take. There is an important aspect of sharing … sharing experiences, challenges. Like for me, when I presented a case, well it was quite confronting, but still, I benefited from many recommendations and ideas. And you know, I think it could have been useful to others as well. (P4).

2.2 Developing one’s competencies by collaborating with CD experts

- There were a lot of cases of schizophrenia, complex situations, who were isolated and what to do to mobilize them again. That, I found that interesting. I remember one time when I told myself: “Hey, I myself wouldn’t know what to do with that”. And I admired the team’s dedication and how they approached that. I really would have needed support if I had been in their situation. Having a vision of loads of mentors from across the region, in the end …I found that to be a rich source of information. (P6).

2.3 Developing one’s competencies by strengthening one’s self-confidence

- Sometimes, you feel like … you’re not good at what you do or you question your abilities a lot precisely when things fail to come to a successful conclusion or you keep going through the same problems with some patients over and over, and to share this with others from regions other than our own … for those of us who do not work in the major urban centers with specialists… So that, too, is reassuring. It’s to see that, in the end, what we manage to do with the means at our disposal, well it’s not bad at all. (P4).

Theme 3:

Factors facilitating competency development and practice change

3.1 Being provided with relevant educational material

- Personally, what I liked a lot was the didactic presentations. And what’s good is that they’re all backed up with references and they’re listed on the website. That’s super interesting because I went and retrieved a few of them. So, what it allows us to do is to base our interventions then on the literature. (P3).

3.2 Feeling a sense of belonging to a community

- You know, you feel a little like you’re not all alone. At times you have questions, and you don’t know who to turn to. So, this (ECHO-CD) was the perfect place to do so. (P2).

3.3 Learning in an interprofessional environment

- In the ECHO sessions on concurrent disorders, well, the panel (team of experts) is interdisciplinary. That, in my opinion, is a winning ingredient there, precisely because our clientele is so varied, so complex and multidimensional. (P3).

3.4 Having access to continuing education through technologies

- What I like about ECHO is the easy access. First, the fact that it’s free makes it accessible to everyone. And then, the fact that the sessions are delivered on Zoom, well, personally I found it helpful to be able to see the people, to be able to discuss things easily. (P8).

Theme 4:

Factors limiting competency development and practice change

4.1 Working with limited resources outside of major urban centers

- I would have liked for our own physicians to be involved more in ECHO, like for them to be more present to be able to gain a greater awareness of what’s going on elsewhere and like stimulate their imagination. It would have been more interesting for us afterwards to put what we learned into practice. Because, as it turns out, sure, there were nice proposals made during ECHO, but… then, I did not have anyone to back me up about trying new treatment options. Because there are a lot of medical decisions to be made as well behind it all. (P5).

4.2 Experiencing lack of support from employer

- Well, what worked against me is that I’ve become a head nurse assistant along the way. That’s why I couldn’t put things into practice or integrate them as much and to try new things out with my patients because … I was really pulled out of that role. (P1).

- What I retained was, I was very passive, in the sense that, I didn’t contribute any case-based discussion. Plus, it took place at a time where I was pretty much alone in my team with a novice nurse, so I didn’t have the time to prepare any cases to present for ECHO. I could have been more assiduous. (P2).

- The computer I was using at work didn’t have a webcam, so I was only able to chat and listen. (P7).

4.3 Learning in group by way of real-time videoconferences

- For sure, I was very much questioning myself in the first sessions. So, when the time came to make recommendations to other participants, well, I had some reservations … I would tell myself: “Well, maybe my vision isn’t necessarily the right one.” (P4)

- We were, my team and I, on one computer, so there was one person in front of the computer, and others in front of a large screen. Consequently, participation wasn’t like optimal, to be able interact, I mean. So, generally, it was more through chat that we’d say: “Write this.” But, at times, the time it took to write that, well, we’d moved on to something else. (P5).