Optimizing online learning resources for substance use professionals in England: lessons from user-centered design

Abstract

Online learning has the potential to improve best practice in substance use treatment by facilitating access to high-quality resources. A user-centered design (UCD) approach can identify the needs, motivating factors, and working contexts of learners.

Aim: The aim of this study was to identify ways of improving online learning for people working in substance use treatment services in England.

Methods: Semi-structured interviews were conducted with 31 substance use professionals in England and 14 other professionals working in the field. Participants were asked about their training needs, working contexts, and current use of online resources. Data were analyzed according to the principles of UCD via Iterative Categorisation.

Results: Participants reported “unmet needs” for training in therapeutic relationships and advanced therapeutic techniques. They enjoyed training that demonstrably improved the quality of life for people who use drugs and that provided career and personal development opportunities. Participants completed many mandatory online courses that were short and unpopular. Access to training was limited by time and financial constraints, with online training partially addressing these barriers.

Conclusion: If online learning is to be optimized, the needs of substance use professionals must be accommodated; however, online learning that meets the needs of substance use professionals does not always match the best evidence.

Keywords:

• Workforce development
• addiction
• user-centered design

Introduction

Online learning has long had the potential to provide cost-effective education over a wide geographical area (Bowen et al., 2014; Deming et al., 2015). The term “online learning” can refer to diverse forms of learning, including informal or certified courses; programs that use a combination of video, audio, and text-based content; and courses that are synchronous (where learners and presenters interact with each other at a set time) or asynchronous (where courses are pre-recorded and accessed at a time of the learner’s choosing).

The first substantial meta-analysis on online learning in healthcare settings was published in 2008 and concluded that online learning can improve the skills, knowledge, and behaviors of healthcare professionals (Cook et al., 2008). There are now several systematic reviews and meta-analyses relating to online resources in healthcare settings (Cook et al., 2008; Cook et al., 2013; Wong et al., 2010; Mccutcheon et al., 2015; Sinclair et al., 2016; Calder et al., 2017; Jackson et al., 2018; Singh & Reyes-Portillo, 2020). Many of these have also concluded that online resources can be as effective as face-to-face learning for changing the knowledge, skills, and behaviors of healthcare professionals.

There are, however, substantial limitations to the literature in this area. The main limitation is that studies are often based on specific educational resources, and the content, format and use of technology of those resources vary across studies, thus preventing researchers from drawing conclusions about online learning as a whole (Calder et al., 2017; Cook et al., 2008; Jackson et al., 2018; Singh & Reyes-Portillo, 2020). Systematic reviewers have suggested that the quality of online learning could be addressed by using formative assessments of prospective learners to understand their learning styles, training needs, and preferences (Calder et al., 2017; Cook et al., 2008; Sinclair et al., 2016; Wong, 2012).

A review of randomized controlled trials (Sinclair et al., 2016) found that the quality of online learning resources differs depending on the subject, the learner’s characteristics, and their working contexts. Two further systematic reviews of online learning in healthcare professions (Calder et al., 2017; Wong, 2012,) recommended that online resources should be designed to meet the needs of learners. One way to meet those needs is to draw on the principles of user-centered design.

User-centered design (UCD) is a theoretical approach that focuses on the “end-user” of a product (Cooper et al., 2014; Wever et al., 2008; Bhamra et al., 2008). The principles of UCD are that products should be designed according to a thorough understanding of that end-user's needs, contexts, motivations, and expectations (Cooper et al., 2014). Online training resources that meet those needs are likely to be successful; those that meet the wider needs of end-users (such as lifestyle or personal development needs) are likely to be perceived as high quality. Contextual factors that deter someone from using online resources are also important (Berge, 2005; Muilenburg & O”doherty et al., 2018) and can include technical skills requirements, technical problems, time constraints, and attitudes. Without understanding the specific barriers encountered by end-users, designs are liable to fail (Cooper et al., 2014).

Substance use professionals’ training in England

Substance use treatment services in England offer medical, psychosocial, and recovery interventions to reduce substance use and its associated harms (Department Of Health [England] And The Devolved Administrations, 2017).

There is little published literature about the training or education needs of substance use professionals in England or the UK. While there are several peer-reviewed articles and national reports that identify their demographic characteristics, education, and qualifications (Albery et al., 2003; Black et al. 2017; Cookson et al., 2014; Farmer, 1995; Gosling, 2017; Luty & Rao, 2008; Mazoruk et al., 2017; Mills et al., 2003; Oyefeso et al., 2008; Schulte et al., 2010; Sheridan et al., 2011; Sinclair et al., 2011; Smith 2011; Sondhi & Day, 2014; WELSH Assembly Government, 2005) very few of these explore training needs. Those that do, use quantitative methods to list training preferences. For example, a National Treatment Agency report from 2003 identified training needs that included “alternative therapies,” “counselling techniques” and “HIV and AIDS” (Mills et al., 2003). One Welsh training needs analysis (Black et al., 2005) identified training needs relating to “fatal, and non-fatal overdose,” “preventing abusive and aggressive behaviour,” “prevention activities,” “providing education,” and “providing support.”

To date, studies (e.g. Albery et al., 2003; Black et al., 2017; Luty & Rao, 2008; Mills et al., 2003; Schulte et al., 2010; Sinclair et al., 2011; Sondhi & Day, 2014; WELSH Assembly Government, 2005) have not explored the needs of substance use professionals beyond subject preferences. The needs, working contexts, motivations, and expectations of substance use professionals remain largely absent from the published literature. This absence of detail is one factor that prevents the optimization of online learning resource design following a UCD theoretical approach and is a factor that the present study aims to address.

In 2021, the importance of optimizing training provision for substance use professionals in the UK was brought into focus by a report led by Professor Dame Carol Black and by the publication of the UK Government's Drug Strategy in 2021 (Black, 2021; UK Government, 2021). Both recommend that the Academy of Medical Royal Colleges (a coordinating body for the UK and Ireland's medical royal colleges) should develop a training center for both the NHS and third-sector workforces. “Third-sector” (sometimes referred to as “voluntary-sector” or as non-governmental organizations - NGOs) originated in small community groups that were based on philanthropic principles (Hedley et al., 1995) and are so-called because they are neither public bodies nor private commercial businesses. Given the increasing use of third-sector organizations to provide substance use treatment (Advisory Council On The Misuse Of Drugs (ACMD), 2017; Recovery Partnership and ADFAM, 2017; Public Health England, 2014), this study will focus on substance use professionals from this sector.

The aim of this study is to identify ways of improving online learning for third-sector substance use professionals. We used four objectives to meet the overarching aim. These were to better understand the education and training needs of substance use professionals; the barriers and facilitators to education and training experienced by substance use professionals; the factors motivating substance use professionals to attend training; and the types of internet resources commonly used by substance use professionals.

Materials and methods

User-centered design employs qualitative research methods to produce in-depth analyses of a product’s end-users. Qualitative methods are valuable for this process because of their ability to provide data that go beyond simply identifying a user’s preferences. To design according to need, one must understand why those preferences exist, which needs they fulfill, and the contextual mediators and moderators of those preferences (Beuscart-Zéphir et al., 2005; Teixeira et al., 2012).

Data generation

We conducted semi-structured interviews with third-sector substance use professionals and key stakeholders (KSH). We defined substance use professionals as people who worked for third-sector organizations and whose work was based on direct contact with service users, and KSH as people who had a professional interest in third-sector substance use treatment training, such as managers, directors, trainers, policymakers and quality assurance assessors.

Third-sector substance use treatment organizations were identified by reviewing National Drug Treatment Monitoring System (NDTMS) reports of publicly-funded substance use treatment in England (Public Health England, 2014). The fifteen third-sector organizations with the highest number of services included in the NDTMS at that time were approached by author RC for participation in the study by email and by telephone.

Substance use professional recruitment

Emails with participant information sheets were sent to all substance use professionals within participating organizations inviting them to complete an online survey (results from that survey are not included here). The initial email was sent to approximately 2500 substance use professionals, of whom 200 (8.0%) completed the online survey, and 100 (4.0%) consented to be approached for an interview. Everyone who participated in that survey (n = 200) was asked if they would consent to be approached for a semi-structured interview. Invitations to the 99 survey participants who consented were stratified to attain a balance of participants’ age, treatment delivery experience, and digital literacy. Twenty-one participants responded to a follow-up email and agreed to be interviewed.

Ten further participants were recruited through snowball sampling whereby existing participants asked colleagues if they would be interested in participating in the study. Those colleagues expressing an interest were sent the participant information sheet and then recruited using the same processes as before. These invitations were not stratified, nor is it possible to know how many people were initially approached by their colleagues. All those contacting RC as a result of snowball sampling were interviewed.

KSH recruitment

Fourteen key stakeholders were recruited opportunistically from the fifteen gatekeeper organizations. They included area managers, commissioners, managers, trainers as well as people working in policy and regulatory settings. First, RC asked organizational contacts if there were any central office staff who would be relevant to the study or if they knew of commissioners who would be appropriate. Those who agreed to be interviewed were then asked to recommend others who might be approached, this resulted in six key stakeholder interviews. The inclusion criterion was that participants needed to have a professional interest in substance use professionals’ training or training policy. Participant information sheets were sent to potential participants and informed consent was gained in advance of interviews.

Substance use professional and KSH interviews

The substance use professionals’ interview topic guide was designed following a review of the literature and according to the principles of UCD (i.e. designed to identify end-user needs, preferences, use of existing resources, and contextual factors). The topic guide was piloted with two substance use professionals and included items on barriers and facilitators to training, demographic characteristics, education and training needs, and motivation to attend training. The KSH interview topic guide was not piloted. The topic guide included items on perceived training needs of substance use professionals, barriers and facilitators to providing training, and wider structural factors.

The substance use professionals’ interviews were conducted between 23 January and 13 December 2017. KSH interviews were conducted between 5 May and 27 November 2017. Each participant was interviewed once. Interviews took place at participants’ places of work, or in a local café if that setting was preferred. All interviews were conducted with just the participant and RC present. Interviews were recorded using an audio recorder and transcribed by RC.

Coding and analysis

The qualitative data were coded and analyzed by RC facilitated by the qualitative software program, MaxQDA. The coding and analysis followed principles of Iterative Categorisation (Neale, 2016). To this end, a coding frame was developed comprising deductive codes, arising from the original questions in the topic guides, supplemented by inductive codes emerging from the interviews. Once all of the interview data had been coded, the text extracts appended to each code were separately reviewed line-by-line and grouped in an iterative process to identify themes and sub-themes. Data from substance use professionals and KSH were also compared and contrasted for similarities, differences, and wider explanations. For example, findings from the KSH data were sometimes able to explain organizational reasons for the type of training provided to substance use professionals. At the end of the analyses, the findings were grouped again, this time according to the four study objectives.

Findings

Participants

RC interviewed 31 people working in a range of third-sector substance use treatment settings (Table 1). Twenty-four identified as female, seven as male; twenty-three as “white British” and eight as "other ethnicity". Nine had a post graduate qualification – predominantly a masters degree, ten held a degree, nine had an NVQ (National Vocational Qualification) or diploma in counselling or “addiction,” and three had GCSEs or A-levels as their highest level of education (UK Government, 2011). Participants had worked in substance use treatment services for between six months and eighteen years and for an average of seven-and-a-half years. Working titles and roles varied considerably, with twenty-nine job titles covering thirty-one participants. Roles included counselors, criminal justice workers, family workers, peer-mentor coordinators, recovery workers, team leaders, and youth workers. The 31 interviews produced 23 hours and 12 minutes of interview data. Interviews lasted for an average of 45 minutes; the shortest interview lasted for 26 minutes and the longest interview lasted for 1 hour and 17 minutes.

Table 1. Substance use professional participant characteristics.

Item	Addiction professionals, n (%)
Age
16–20	1 (3.2)
21–30	5 (16.1)
31–40	8 (25.8)
41–50	11 (35.5)
51–65	6 (19.4)
65+	0 (0.0)
Not reported	0 (0.0)
Gender
Male	7 (22.6)
Female	24 (77.4)
I prefer not to say	0 (0.0)
Ethnicity
White British	23 (74.2)
All other ethnicity	8 (25.8)
Highest level of education
GCSE / A-level	3 (9.7)
NVQ / Diploma	9 (29.0)
Degree	10 (32.3)
MSc and above	9 (29.0)

Note: GCSE: General Certificate of Secondary Education; NVQ: National Vocational Qualifications; MSc: Master of Sciences.

We interviewed 14 KSH; their working and demographic characteristics are not described here because doing so would enable some of them to be identified. The 14 KSH interviews produced 13 hours and 12 minutes of interview data. The average interview duration was 56 minutes. The shortest interview lasted for 30 minutes and the longest interview lasted for 1 hour and 21 minutes.

Objective 1: the education and training needs of substance use professionals – subject preferences

Substance use professionals: education and training needs

Most participants thought that staff should have training in developing therapeutic relationships. Many said that they had been offered training courses in therapeutic skills (such as motivational interviewing) by their employer organization, but no participants could identify training on therapeutic relationships. Several participants doubted it was possible to learn therapeutic relationship skills suggesting they were natural skills for some people.

“I think it [therapeutic relationships skills] probably comes more naturally to some people than others, I’m sure those people that it does come naturally to are probably attracted to these sort of careers. So maybe you know maybe some people don’t need training in that sort of thing. But I think it”s helpful.”

Tony: Non-specialist project worker

Most participants said that motivational interviewing was important; otherwise, there was little agreement on which therapeutic skills were essential. Some participants referred to cognitive behavioral therapy (CBT), recovery, group work, and harm reduction. Alongside therapeutic skills, many participants said that new staff should access training on basic “drug awareness”. Some suggested that this was best learned “on the job,” by talking to colleagues and service users.

Many participants said that shadowing and peer learning were good forms of training, noting that this form of learning occurred during case reviews, informal discussions, team meetings, and supervision. Shadowing was routinely organised for new staff although no participants described any structure or learning objectives relating to this.

Most participants said that their job required substantial administrative skills but that administrative training was rarely offered. Participants knew that administrative skills were important and wanted to improve, but simultaneously did not want to spend time focusing on them. Most said they learned administrative skills by asking colleagues for help.

“I’ve never been given formal IT training, it’s just things you pick up. And I think that would be really helpful because particularly with data there’s an expectation to fulfil particular data requirements. And a lot of er colleagues say “oh I’ve become a data worker” without really being given the skills or how to do typing."

Harriet: Team leader

Almost all participants accepted that mandatory training courses were necessary. They also agreed that those courses were unpopular. Most mandatory training courses were accessed online and were asynchronous, comprising pre-recorded material that was completed at the learner’s pace. These were mandated by participants’ managers or employing organisations. Participants said that the need to complete these courses was driven by regulatory requirements coming from commissioners or from the need to pass a Care Quality Commission (CQC – the independent regulator of health and social care in England) inspection. Mandatory training course subjects included assessments, blood-borne viruses (BBVs), CBT, data protection, desktop safety assessments, fire safety, health and safety, information governance, the Mental Capacity Act, motivational interviewing, policies and procedures, safeguarding children and safeguarding vulnerable adults.

KSH: education and training needs of substance use professionals

KSH participants were aware that mandatory training courses were unpopular among substance use professionals but said that they continued to use them because of the need to comply with regulatory and legal requirements. Mandatory courses identified by KSH included assessments, blood-borne viruses (BBVs), CBT, data protection, desktop safety assessments, equality and diversity, fire safety, health and safety, information governance, the Mental Capacity Act, motivational interviewing, policies and procedures, safeguarding children and safeguarding vulnerable adults.

Several KSH said that the importance of administrative work was similar to that of regulatory compliance using the legal implications of good record-keeping as an example. One commented that good administrative skills helped staff report, record and refer service users, arguing that good administrative skills could keep people safe and help them access the right treatment. One participant said that their organization had administrative training available for staff; however, most acknowledged that administrative training was not a priority.

“We make an assumption, I make an assumption that somebody’s walked through the door and got the job that they can write an email, write a report…. People write God knows what, people don’t realise that emails are a legal document, coroner’s reports that kind of stuff.”

Sofia: Senior management (KSH)

Outside of regulatory requirements, most KSH participants said that therapeutic skills were a core training need, arguing that they provided a basis on which other treatments and interventions could be delivered. Motivational interviewing was commonly discussed followed by behavioral couples therapy, brief solution-focused therapy, care planning, CBT and harm reduction.

Several KSH participants described the centrality of developing a good therapeutic relationship. Some KSH said that general communication skills, manners, and customer care were all part of building therapeutic relationships. As with the substance use professionals participants, none could identify any therapeutic relationship skills training, and some expressed doubt about whether those skills could be taught.

“INTERVIEWER: And do you think that’s something that you can train that ability to talk to people gain a therapeutic relationship those things.

PARTICIPANT: No, I don’t think… no I think it… I don’t know I think you’ve either got it or you haven’t really.”

Tessa: Regulatory work (KSH)

Objective 2: the barriers and facilitators to education and training

Substance use professionals: barriers to training

The most common barrier to training reported by substance use professional participants was a lack of time because of high workloads. Several participants described having to complete training in their own time.

“Who do you cancel? What phone call are you going to refuse to take? …It’s just a nightmare. So, most of mine was done at home. In fact, 90% of my NVQ level 3 was done at home.”

Jenny: Non-specialist project worker

Many participants said that they were reluctant to attend training because their work colleagues would have to cover their work. Some explained that their home life or childcare commitments prevented them from attending training. Training location was another barrier for people who worked in remote locations, and travel to training courses could be too costly or time-consuming to fit into a working day.

In addition to practical constraints, many participants reported financial barriers to training. No participants stated that their training applications had been rejected because of a lack of money; rather they said that knowing the cost of training and their services’ financial constraints prevented them from applying for multiple, or expensive, training courses.

Beyond financial constraints, many substance use professional participants said there were few advanced-level training courses. The impact of this was particularly acute for those who had worked in the sector for a long time and had therefore completed all basic training available. Some noted that there was often a waiting list for advanced courses that needed to be full before the course was run.

“There’s a few training courses that I want to get on at the moment but it’s just like getting the numbers up. One of them has actually just been cancelled. So um, just waiting.”

Pumula: Non-specialist project worker

Substance use professionals: facilitators to training

Generally, participants acknowledged that the short, asynchronous courses delivered online or at their place of work were easy to access because they could be fitted around work. Many participants said, however, that they enjoyed the experience of longer face-to-face training courses and did not enjoy the experience of short online courses. Negative views of the latter are discussed in more detail later but relate to the predominance of regulatory requirement subjects and the lack of personal interaction.

Access to training was improved where managers were supportive of training by, for example, arranging cover and paying travel costs in advance. Some organizations were supportive of personal development, although many felt that organizational training priorities were based on regulatory requirements rather than on their own needs. Accordingly, regulatory requirements were a strong facilitator for training, with mandatory training made widely accessible.

“Yeah, and if I’m being really really really honest, training wasn’t great until we had a CQC inspection, and it was picked up on and then there was a drive and we had loads of training for a while.”

Paula: Non-specialist project worker

KSH: barriers to training

The most common barrier to training identified by KSH participants was releasing substance use professionals from services to attend training. In particular, KSH talked about the difficulty of maintaining staff cover.

“Just having to alter your operations on the day and look at things like cover and … because of the way we operate and it’s quite tight in terms of rota duties as well as client load as well as everything else.”

Maya: Service manager (KSH)

Difficulties in ensuring service continuation were particularly acute for people wanting to attend distant or long training courses. Sometimes services would have to fund travel and accommodation in addition to the cost of training and the cost of agency staff.

“Um, and then that’s without you know if the training is flippin’ miles away then they’ll build up TOIL [time-off-in-lieu] as well (laughs)…Yeah when I hear that the training’s in [name of local town] I’m like ‘oh thank God’.”

Maya: Service manager (KSH)

Several KSH (none of whom was a service manager) said that service managers could block training attendance for substance use professionals. Some KSH participants said that persuading managers to support training was as important as persuading substance use professionals. The attitudes of managers and organizations could vary; one KSH participant recalled working for an organization that allocated a set number of training days each year to all staff. Conversely, another KSH participant recalled working for an organisation that treated training as a form of punishment.

“And I think there’s sometimes an issue around attitudes towards the idea of training and people’s perception of what it is. And sometimes managers perceptions of what it I, um is that you’ve done something wrong so I’m going to send you on training. It’s like training as a punishment.”

Ben: Training (KSH)

KSH: facilitators to training

The facilitators to training attendance and provision from KSH’s perspectives comprised removal of the barriers to training discussed above.

Objective 3: factors motivating substance use professionals to attend training

Substance use professionals: motivation to attend training

Substance use professional participants were particularly interested in opportunities to improve their work with service users. Indeed, a desire to improve the quality of treatment was the single largest motivation for training reported by participants. Alongside this, small but direct interventions such as acupuncture or mindfulness were popular if participants felt that they gained a tangible skill that they could immediately apply in their work with service users.

“Maybe like mindfulness or something like that that I could do or deliver to my clients.”

Audrey: Groupworker

Substance use professional participants also said they were motivated to attend training that would develop their careers. Other participants were motivated by opportunities for personal, rather than career, development such as gaining skills and personal insights. This form of motivation was often aligned to training in therapeutic techniques.

Many participants were motivated to attend training in order to increase their confidence. This was often related to their confidence in delivering therapeutic interventions but also to liaise with other professionals. Some participants said that having a substance use-specific qualification would help their views carry more weight when talking to other professionals such as doctors and social workers.

KSH: motivation of substance use professionals to attend training

KSH participants who worked in training provision noted that training courses in benzodiazepines, CBT, compassion fatigue (a type of burn-out), ‘“grey areas” and working with uncertainty, harm reduction and needle exchange, motivational interviewing, new drugs, leadership training, performance-enhancing drugs, research updates, safer injecting, solution-focused brief therapies and synthetic cannabinoids such as “spice” were popular. Those KSH participants thought that the practical application of these training subjects, and their relevance to work, were the key reasons they were popular.

“I think it’s people, especially CBT, they like the idea of being able to deliver it and the sort of counselling side of things as well.”

Jasmine: Training (KSH)

Some KSH participants suggested that substance use professionals might be motivated to attend courses that had certification, that had a good reputation, and that were “exclusive,” reflecting the need for career progression among substance use professional participants.

KSH acknowledged that there were low levels of motivation among substance use professionals for completing mandatory online training courses. Some added that this low motivation was one reason why those training courses had become mandatory in the first place.

Several KSH participants said that low-quality training courses could compound negative views of training among substance use professionals and that requiring them to complete an NVQ in Health and Social Care had diminished motivation for future training because it had taken a lot of time and had produced few tangible benefits.

Objective 4: the types of internet resources commonly used by substance use professionals

Substance use professionals: commonly used internet resources

Most online learning completed by substance use professional participants were mandatory training courses. These were usually based on a series of slides followed by a multiple-choice questionnaire and were almost universally asynchronous, thus containing no opportunity to interact with peers or presenters. Most courses were driven by regulatory requirements as discussed above.

Some participants said they enjoyed interactive animations, case studies, and videos in online learning, but noted that these were rarely included in mandatory courses. Several said they would largely ignore the content of mandatory courses and skip to the multiple-choice questionnaire at the end. Some rationalized this, saying that mandatory courses were intended to audit compliance rather than to train staff.

Substance use professional participants also talked more generally about “looking things up” using Google. One participant said that their ability to find information online could diminish the importance of structured training.

“Um did one [training course] recently the Mental Capacity Act…. It was just going in one ear and out the other. It just seemed like there was so much to learn and it felt like ‘well what’s the point because if the time ever comes that I need to be looking at a client’s capacity and working with a client who possibly lacks capacity I’ll be finding out at the time, and I’ll be crossing that bridge when I come to it'.”

Tony: Non-specialist project worker

Most participants said that content, rather than format, was important, and if the online content answered their questions, they would find the experience of using that website satisfying. Despite this, many also endorsed websites that had simple layouts and that were easy to navigate, suggesting that format was also an important factor. This suggests that issues relating to both content and format must be addressed for resources to be optimized. Both content and format can act as a barrier and as a facilitator and both need to be considered in the light of the evidence of need from substance use professionals.

Several participants said that websites were satisfying if they functioned with minimal errors, adding that errors on websites could prevent them from being used.

“I just sort of find my way around most things … and if I really can’t I won’t. I’ll just sack it off, you know I’ll delete it do you know what I mean?”

Natalie: Non-specialist project worker

KSH: commonly used internet resources

KSH participants reported that they appreciated being able to identify which substance use professionals had completed which mandatory training courses. In addition, several KSH participants said that they thought online learning methods were effective for information-based subjects, but less so for skills-based training.

“We’re updating our two-day CBT face-to-face training but it is going to involve an online module so basically all their introduction stuff, all the information, I think can all go online, but it’s more sort of practising yourself, practicing interventions, role playing with other practitioners, which I think has to take place face-to-face.”

Jasmine: Training (KSH)

Discussion

Summary of key findings

The present study identified training needs in therapeutic techniques, such as motivational interviewing, and in building therapeutic relationships. Barriers to training included financial and organizational factors, the impact of which could often be diminished by using online training methods. Participants were motivated to attend training that was linked to improved quality of life for service users or that helped them develop personally or professionally. Most online training for substance use professionals seemed to focus on mandatory asynchronous online courses that were designed to meet regulatory requirements. Online learning was largely unpopular and treated as an administrative requirement rather than as a learning opportunity. Many participants accessed informal training on the job, either by speaking to colleagues, shadowing, or searching the internet.

The need for training in therapeutic skills such as group work, motivational interviewing, and recovery, align with Mills and colleagues (Mills et al., 2003) identification of “counselling through recognised methods.” That online learning was viewed by many participants as ineffective suggests that the negative view of “e-learning” identified by Smith and colleagues in 2011, where just 20% of people preferred e-learning (Smith, 2011), has persisted and perhaps increased. Online resources have changed considerably over the past 10 years (Mayer, 2018; Singh and Thurman, 2019; Williamson et al., 2020), it is, therefore, interesting to note that online training remained unpopular at the time of data collection. That service managers and employer organizations could support or prevent access to training reflects previous findings relating to the importance of extrinsic motivating factors (Hartnett et al., 2011; Wong, 2012).

The negative experiences of online learning suggest that there had been little consideration of the needs and contexts of substance use professionals by people designing online learning (Cooper et al., 2004, Gulliksen et al., 2003). The foundations of UCD are in designing resources that create a positive experience and that meet end-users' needs and engender repeated use and engagement with the content (Bhamra et al., 2008; Wever et al., 2008). It is therefore important that approaches such as UCD are used to address the low opinion of online learning because that opinion risks reducing the engagement and effectiveness of this form of learning. This issue is central to the effectiveness of training, which is, in turn, central to dissemination (Chan et al., 2011; Sondhi & Day, 2014). Positive experiences of training do not merely help the substance use professional; they may also improve treatment delivery and improve outcomes for those seeking help for substance use (Miller et al., 2006; Hartzler et al., 2014).

A central finding of the present study is that most participants were motivated to improve the lives of people who use drugs. There were, however, several differences between the training that participants were motivated to attend and the interventions with the best evidence of effectiveness; for example, there was a high motivation for training in mindfulness and for acupuncture as interventions that could be “given” to a service user. There were comparatively few mentions of training in contingency management despite its strong evidence base (Getty et al., 2019; Prendergast et al., 2006). Training that does not meet the motivations of substance use professionals is less likely to be perceived to be high quality than one that does (Calder et al., 2017; Wong, 2012); however, training that solely responds to those motivations risks encouraging a workforce to deliver treatments based on popularity rather than on evidence of effectiveness. In the hands of a skilled trainer, however, courses that sit outside the needs of substance use professionals may still be engaging (Doherty & Nugent, 2011), and meeting substance use professionals’ need is one part of a range of issues that improve quality (Cook et al., 2008).

In 2021, the UK government committed to increased funding and staffing for substance use treatment (Black, 2021; UK Government, 2021) which may address some time and resource barriers to training that were identified here. Increased funding may improve access to training; however, the attitudes toward online learning, for example, will not be addressed by resources alone (Sinclair et al., 2016; Wong, 2012). The potential benefits of online training may be at risk if the experiences of completing mandatory training courses identified in the present study continue to dominate. KSH talked about the importance of high-quality training, observations that were at odds with their views of the online mandatory training courses that they thought were low quality but essential. Most were motivated to provide more dynamic training, but at the same time were resigned to the suboptimal situation reported here.

Effective online learning designers should design according to the needs and contexts of substance use professionals and KSH as the “customer” (Cooper et al., 2014), although there are likely to be differences between service users' needs and the needs of substance use professionals. The present study focused on the latter but acknowledges that tension can exist when the needs of a substance use professional (e.g., for training in acupuncture) differ from those of service users.

Where possible, designers should focus on therapeutic subjects, and overtly demonstrate that the learning will help improve the lives of people who use drugs, whilst increasing substance use professionals' career opportunities and personal development. Furthermore, if the training can meet regulatory requirements, then it may receive further backing from key stakeholders.

Online learning had a poor reputation among participants, often due to its extensive use in mandatory training courses where neither the content nor format seemed to be engaging for participants. Online learning designers need to demonstrate that online learning can be useful and enjoyable to a potentially skeptical audience. The ability to save progress, re-start a training course and interact with fellow learners and presenters could be important.

Limitations and strengths

The data presented here are from 2017 and some findings may now be dated. It is of particular note that the COVID-19 pandemic and associated lockdown regulations had a substantial impact on substance use treatment provision (Ornell et al., 2020). This has led to increased interest in online learning and telehealth (Dhawan, 2020; Oesterle et al., 2020). The study was limited to substance use professionals and KSH in third-sector substance use treatment organizations in England and so findings may not be transferrable to other settings, organizations or countries. The response rate for substance use professionals was very low which severely limits the transferability of the findings. The resulting sample contained several notable biases including a predominance of people aged between 41 and 50, of women and of white participants. The data collected about participants were also limited and did not include information on their professional background, nor did we collect information outside of the interviews on the types of online learning they were provided. Accordingly, reports in the present study are from the perspective of participants and were not cross-checked with provider organizations. It is also important to note, that the data presented here concern just one approach to training quality and do not cover pedagogical approaches and interactive design principles. Multiple approaches must be considered if online learning is to be optimized as a method of disseminating evidence-based findings into practice.

The data presented in the present study are focused on the needs of substance use professionals rather than necessarily on the technology used to deliver training, and whilst that technology may have developed since the data were collected (although there is little evidence of substantial change), the needs of that workforce are likely to remain unchanged. Indeed, the urgent appeal for workforce development reported by Dame Carol Black (Black, 2021) indicates that many needs among substance use professionals remain unmet. This study necessarily focused on a specific group (third-sector substance use professionals); however, their centrality to substance use treatment provision in the UK means that the impact of their training, professional development and ability to deliver evidence-based practice is not of marginal importance. The response rate remains a limitation, one that illustrates the disconnect between research and clinical practice. We would encourage future researchers to explore establishing co-working with third-sector substance use treatment organizations so this can be improved.

This was the first in-depth peer-reviewed qualitative study to identify the training needs, motivations, and working contexts of third-sector substance use professionals in England. It is also the first to use principles of UCD to guide the research. It meets a substantial gap in the literature, has direct and practical implications for policy, training, and dissemination and provides a base on which future research can build. The inclusion of KSH added a perspective that was missing from previous training needs studies and gives essential information for those developing training.

Conclusions

Online learning has the potential to meet previously unmet needs of substance use professionals and to improve access to high-quality training. Designers of online learning (and, indeed face-to-face learning) should design learning resources according to the identified needs of substance use professionals and key stakeholders in order to engender a positive user experience. This will enable such resources to realize the opportunities of using the internet to improve the dissemination of evidence-based practice in substance use treatment settings.

Ethical approval

Ethical approval was granted on 14 April 2016 from King’s College London Psychiatry, Nursing, and Midwifery Research Ethics Subcommittee; reference number LRS-15/16-1913 (subsequently transferred to RESCM-17/18-1913). No participants were deemed to be vulnerable. All participants provided informed consent before participating in the study and all participants have been given pseudonyms to protect their anonymity.

Acknowledgements

The authors are grateful to the participants and participating organizations for their time in contributing to this study. The research was funded by a King's College London, Institute of Psychiatry, Psychology and Neuroscience studentship and was independent of external or business funding.

Disclosure statement

In the last three years, J.N. has received, through her university, research funding from Mundipharma Research Ltd and Camurus AB (for unrelated research) and honoraria from Indivior and Camurus AB (for unrelated webinars). The Authors report there are no other competing interests to declare.

Additional information

Funding

The research was funded by a Kings College London, Institute of Psychiatry, Psychology and Neuroscience studentship and was independent of external or business funding.