The Humble Leader: Association of Discrepancies in Leader and Follower Ratings of Implementation Leadership With Organizational Climate in Mental Health

Supervisory Alliance as a Moderator of the Effects of Behavioral Rehearsal on TF-CBT Fidelity: Results from a Randomized Trial of Supervision Strategies

Exposure is an important element of treatment for many evidence-based treatments but can be challenging to implement. Supervision strategies to support exposure delivery may be an important tool to facilitate the use of exposure techniques; however, they must be considered and used in the context of the supervisory alliance. The present study examined relations between supervisory alliance and fidelity to the trauma narrative (TN; i.e., imaginal exposure) component of Trauma-Focused Cognitive Behavioral Therapy. We also examined how supervisory alliance moderated the effect of behavioral rehearsal use in supervision on TN fidelity. We analyzed data from a randomized controlled trial, in which forty-two supervisors and their clinicians (N = 124) from 28 Washington State community-based mental health offices participated. Clinicians were randomized to receive one of two supervision conditions-symptom and fidelity monitoring (SFM) or SFM with behavioral rehearsal (SFM + BR). Supervisory alliance alone did not predict delivery (i.e., occurrence) or extensiveness of delivery of the trauma narrative. Client-focused supervisory alliance moderated the effectiveness of behavioral rehearsal-as client-focused alliance increased, the odds of delivering the TN also increased significantly. Future research should further investigate how to appropriately match supervision techniques with supervisory dyads and explore the interplay of alliance with supervision techniques a supervisor might employ.

Advancing our understanding of humble leadership in healthcare: a scoping review

PURPOSE

This study aims to advance the understanding of humble leadership (HL) in health care.

DESIGN/METHODOLOGY/APPROACH

This study presents a scoping review to explore and synthesize the existing knowledge in the literature. The search process encompassed three main online databases, PubMed, Scopus and Web of Science. Due to the novelty of the topic of HL in health care and the lack of research in this area, all articles published until the end of February 2023 were considered in this study.

FINDINGS

A total of 18 studies were included. The results showed that in the period of 2019-2023 more attention was paid to HL in health care than in previous years. The research design used in these articles included quantitative (n = 13) and qualitative (n = 5) methods and the statistical population included nurses, hospital employees and health-care department managers. Based on the results obtained, the definition of HL can be divided into two general approaches, including self-evaluation and the way one treats others. In addition, humble leaders in the health-care sector should exhibit certain behavioral characteristics and finally, the results indicated that HL has several positive consequences; however, little attention has been paid to the factors influencing HL in health care.

PRACTICAL IMPLICATIONS

This research will help practitioners gain a deeper understanding of the various applications of HL in health care.

ORIGINALITY/VALUE

To the best of the authors' knowledge, no comprehensive research review has yet been conducted on the application of HL in health care.

Uncovering determinants of perceived feasibility of TF-CBT through coincidence analysis

Introduction

A mental health provider's perception of how well an intervention can be carried out in their context (i.e., feasibility) is an important implementation outcome. This article aims to identify determinants of feasibility of trauma-focused cognitive behavioral therapy (TF-CBT) through a case-based causal approach.

Method

Data come from an implementation-effectiveness study in which lay counselors (teachers and community health volunteers) implemented a culturally adapted manualized mental health intervention, TF-CBT, delivered to teens who were previously orphaned and were experiencing posttraumatic stress symptoms and prolonged grief in Western Kenya. The intervention team identified combinations of determinants that led to feasibility among teacher- and community health volunteer-counselors through coincidence analysis.

Results

Among teacher-counselors, organizational-level factors (implementation climate, implementation leadership) determined moderate and high levels of feasibility. Among community health volunteer-counselors, a strong relationship between a clinical supervisor and the supervisee was the most influential determinant of feasibility.

Conclusion

Methodology and findings from this article can guide the assessment of determinants of feasibility and the development of implementation strategies for manualized mental health interventions in contexts like Western Kenya.

Plain Language Summary

A mental health provider's perception of how easy a therapy is to use in their work setting (i.e., feasibility) can impact whether the provider uses the therapy in their setting. Implementation researchers have recommended finding practices and constructs that lead to important indicators that a therapy will be used. However, limited research to our knowledge has searched and found practices and constructs that might determine feasibility of a therapy. This article uses existing data from a large trial looking at the continued use of a trauma-focused therapy to find practices and constructs that lead to moderate and high levels of feasibility. We found that in settings with a strong organizational structure that organization and leadership support for the therapy led to teachers in Kenya to perceive the therapy as easy to use. On the other hand, in settings with a weaker organizational structure, outside support from a clinical supervisor led to community health volunteers in Kenya perceiving the therapy as easy to use. The findings from this article can guide context-specific recommendations for increasing perceived therapy feasibility at the provider-, organization-, and policy levels.

An evaluation of implementation climate in inpatient maternity care: a cross-sectional survey study

OBJECTIVE

Researchers in obstetrics and gynecology are continuously generating new evidence to inform clinical care delivery. Yet, much of this newly emerging evidence fails to be rapidly and effectively integrated into routine clinical practice. Implementation climate refers to clinicians' perceptions of to what degree organizations support and reward use of an evidence-based practice (EBP) and is an important construct in the science of implementation in healthcare. Little is known about implementation climate for EBPs in maternity care. Thus, we aimed to (a) determine the reliability of the Implementation Climate Scale (ICS) for use in inpatient maternity care, (b) describe implementation climate in inpatient maternity care overall, and (c) compare individual perceptions of implementation climate between physician and nursing clinicians on these units.

STUDY DESIGN

We performed a cross-sectional survey of clinicians in inpatient maternity units across 2 urban, academic hospitals in the northeastern United States in 2020. Clinicians completed the 18-question validated ICS [scored 0-4]. Scale reliability by role was evaluated using Cronbach's α. Subscale and total scores were described overall and compared by physician versus nursing role using independent t-tests, as well as linear regression to control for confounders.

RESULTS

111 clinicians completed the survey (physicians = 65; nursing = 46). Physicians were less likely to identify as female (75.4% vs. 100.0%, p < .001), but were of similar age and years of experience as nursing clinicians. Reliability of the ICS was excellent, with Cronbach's α of 0.91 and 0.86 among physicians and nursing clinicians, respectively. Scores were notably low for implementation climate in maternity care overall and for all subscales. ICS total scores were also higher among physicians as compared to nurses (2.18(±0.56) vs. 1.92(±0.50), p = .02), which remained significant in multivariable modeling (p = .02). Unadjusted subscale scores were higher among physicians in Recognition for EBP (2.68(±0.89) vs. 2.30(±0.86), p = .03) and Selection for EBP (2.24(±0.93) vs. 1.62(±1.04), p = .002). After adjustment for potential confounders, subscale scores for Focus on EBP (p = .04) and Selection for EBP (p = .002) were all higher among physicians.

CONCLUSIONS

This study supports the ICS as a reliable scale for measuring implementation climate in the inpatient maternity care setting. Notably lower implementation climate scores across subscales and roles compared to other settings may underlie the vast evidence to practice gap in obstetrics. In order to successfully implement practices that reduce maternal morbidity, we may need to focus on building educational support and rewarding EBP utilization on labor and delivery units, with an emphasis on nursing clinicians.

Validity and reliability of the transculturally adapted Spanish version of the Implementation Leadership Scale (ILS)

BACKGROUND

There is a need for pragmatic and reliable measures of sound factors that affect evidence-based practice (EBP) adoption and implementation in different languages and cultural environments. The Implementation Leadership Scale (ILS) is a brief and efficient measurement tool of strategic leadership for EBP implementation. The objective of this study was to assess the psychometric properties of the Spanish version of the ILS.

METHODS

The process of translation of the original ILS into Spanish consisted of forward translation, panel meeting, and back-translation. Scale face and content validity compared to that of the original version were assessed and ensured before agreement on the final version. Psychometric properties were examined in 144 healthcare professionals (family physicians, pediatricians, practice and pediatric nurses) involved in implementation or improvement research projects. ILS factor structure was tested by confirmatory factor analysis (CFA). Reliability was assessed by internal consistency analysis. The Pearson correlation between the ILS and the Organizational Support dimension of the Organizational Readiness for Knowledge Translation (OR4KT) questionnaire in the subsample of pediatricians and pediatric nurses (n = 52) was estimated for convergent validity analysis.

RESULTS

The CFA results indicated that the original four theorized first-order factors with a second-order Implementation Leadership factor fit the data well (χ2 = 107.70; df = 45; p < 0.001). All standardized first- and second-order factor loadings were statistically significant. Fit indexes showed acceptable figures (GFI = 0.90; CFI = 0.97; RMSEA = 0.10; SRMR = 0.053). Cronbach's alpha coefficient for the four dimensions of ILS ranged from 0.90 to 0.97, while the reliability estimated for the total scale was 0.95. Results of convergent validity revealed high correlation (r = 0.56) between the ILS and the OR4KT's Organizational Support dimension.

CONCLUSION

The CFA results demonstrated that the tested first- and second-order factor structure of the 12-item Spanish version of the ILS is consistent with the factor structure of the original tool. The availability of the ILS will allow Spanish-speaking researchers to assess and advance understanding of the implementation leadership construct as a predictor of organizational implementation context.

Misalignment in Community Mental Health Leader and Therapist Ratings of Psychological Safety Climate Predicts Therapist Self-Efficacy with Evidence-Based Practices (EBPs)

Therapist self-efficacy in delivering evidence-based practices (EBPs) is associated with implementation outcomes, including adoption and sustainment in community mental health settings. Inner context organizational climate, including psychological safety, can proximally shape therapist learning experiences within EBP implementation. Psychologically safe environments are conducive to learning behaviors including taking risks, admitting mistakes, and seeking feedback. Organization leaders are instrumental in facilitating psychological safety, but may have differing perspectives of organizational climate than front-line therapists. Discrepant leader and therapist views of psychological safety may have independent associations with therapist EBP learning and implementation outcomes over and above average therapist perceptions of climate. This study examined survey data from 337 therapists and 123 leaders from 49 programs contracted to deliver multiple EBPs within a study examining determinants of sustainment within a large system-driven implementation. Both leaders and therapists completed measures of psychological safety climate and therapists reported on their self-efficacy in delivering multiple EBPs in children's mental health services. Polynomial regression and response surface analysis models were conducted to examine the associations of therapist and leader reports of psychological safety and therapist EBP self-efficacy. Greater discrepancies between leader and therapist reports of psychological safety, in either direction, were associated with lower therapist EBP self-efficacy. Alignment in leader and therapist views of psychological safety climate may impact EBP implementation outcomes. Strategies for improving alignment in perceptions and priorities among organizational members can be included in organizational implementation interventions and may represent unexamined implementation mechanisms of action.

Perceptual differences in nursing implementation leadership and climate: a cross-sectional study

BACKGROUND

The literature on perceptual differences between managers and staff regarding social dynamic factors (e.g., leadership, climate) in nursing settings is sparse. Addressing this gap in knowledge is critical for informing implementation efforts and improving patient and organizational outcomes. The purpose of this study was to test the perceptual differences regarding implementation leadership and implementation climate between nursing staff and their managers.

METHODS

This study was a secondary analysis of cross-sectional survey data collected in 2016-2017. The setting included 22 adult medical-surgical units nested in 7 acute care hospitals in the Eastern and Midwestern United States. Participants were registered nurses (N = 261) and nurse managers (N = 22) who completed an electronic survey consisting of the Implementation Leadership Scale (ILS), the Implementation Climate Scale (ICS), and demographic items. Differences in perception were analyzed at the unit level using structural equation modeling to develop latent difference score models (LDS). We assessed associations of the LDSs with manager ILS and ICS scores, years of nursing experience, and years of experience working on the current unit. The association of ILS LDS with the observed nursing staff ICS scores was also analyzed.

RESULTS

Higher manager scores on the ILS and ICS were associated with greater perceptual differences in implementation leadership and implementation climate. Greater years of experience as a nurse were associated with greater perceptual differences in ILS and ICS scores. Greater tenure on the unit was associated with smaller differences on the ILS knowledge domain. Greater perceptual differences regarding implementation leadership were associated with worse staff ratings of implementation climate.

CONCLUSIONS

Although this study observed significant relationships among manager ILS and ICS scores, staff-manager perceptual differences, and staff ratings of implementation climate in nursing settings, it is still unclear why perceptual differences in implementation leadership and climate exist and how to address them. Future studies are warranted to test the effect of perceptual differences on implementation and patient outcomes.

Implementation readiness for evidence-based autism practices in school systems

Background

The increase in the number of autistic children being identified has led to increased demand on public schools to provide high-quality services. Effectively scaling up evidence-based practice (EBP) use for autistic students is challenging, given the complicated organization of special education. Teachers have significant challenges implementing autism EBP with fidelity. Factors such as implementation leadership and climate and attitudes toward EBP are linked to successful EBP use and may vary at different levels of the education system. Examining mechanisms of successful implementation is a critical step to support scale-up.

Method

In this observational study, conducted from September 2018 to March 2020, California school personnel (n = 2273) at multiple levels of the system completed surveys related to implementation climate, leadership, and attitudes toward EBP. Data were collected throughout California at the Special Education Local Plan Areas, County Office of Education, and district and school levels from educators and administrators working in public schools supporting autistic students. Multi-level modeling was conducted to characterize implementation readiness.

Results

Overall, implementation climate and leadership scores are low across levels with regional levels rated more positively than districts or schools. Attitudes toward EBP were moderate, with those working in schools having the poorest ratings and specialists/trainers and related service providers (e.g., speech-language pathologists) having the highest ratings.

Conclusions

Outcomes provide a unique opportunity to compare implementation factors across organizational levels with a large, statewide sample. These data provide guidance for developing implementation interventions at multiple levels of the education system to increase readiness for effective scale-up of autism EBP in schools. Personnel and leaders at different organizational levels may need differentiated training targeting improved implementation climate and leadership. Personnel within districts and schools may experience a particular benefit from leadership support for EBP implementation.

Care team and practice-level implementation strategies to optimize pediatric collaborative care: study protocol for a cluster-randomized hybrid type III trial

BACKGROUND

Implementation facilitation is an effective strategy to support the implementation of evidence-based practices (EBPs), but our understanding of multilevel strategies and the mechanisms of change within the "black box" of implementation facilitation is limited. This implementation trial seeks to disentangle and evaluate the effects of facilitation strategies that separately target the care team and leadership levels on implementation of a collaborative care model in pediatric primary care. Strategies targeting the provider care team (TEAM) should engage team-level mechanisms, and strategies targeting leaders (LEAD) should engage organizational mechanisms.

METHODS

We will conduct a hybrid type 3 effectiveness-implementation trial in a 2 × 2 factorial design to evaluate the main and interactive effects of TEAM and LEAD and test for mediation and moderation of effects. Twenty-four pediatric primary care practices will receive standard REP training to implement Doctor-Office Collaborative Care (DOCC) and then be randomized to (1) Standard REP only, (2) TEAM, (3) LEAD, or (4) TEAM + LEAD. Implementation outcomes are DOCC service delivery and change in practice-level care management competencies. Clinical outcomes are child symptom severity and quality of life.

DISCUSSION

This statewide trial is one of the first to test the unique and synergistic effects of implementation strategies targeting care teams and practice leadership. It will advance our knowledge of effective care team and practice-level implementation strategies and mechanisms of change. Findings will support efforts to improve common child behavioral health conditions by optimizing scale-up and sustainment of CCMs in a pediatric patient-centered medical home.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT04946253 . Registered June 30, 2021.

Validation of the Norwegian versions of the Implementation Leadership Scale (ILS) and Multifactor Leadership Questionnaire (MLQ) in a mental health care setting

Background

The implementation of evidence-based practices (EBPs) is of crucial importance in health care institutions and requires effective management from leaders. However, there is a lack of assessment tools sufficient to evaluate the degree to which the employees´ rate how well their leaders are at implementing EBPs. This emphasises the need for validated and widely used scales relevant for EBPs.

Methods

The current study evaluated the psychometric properties of the Multifactor Leadership Questionnaire (MLQ) and Implementation Leadership Scale (ILS) in a Norwegian mental health care setting.

Results

Results from confirmatory factor analyses indicate that the MLQ and ILS are valid instruments for measuring general and implementation leadership. The scales demonstrate good convergent validity. In addition, attitudes towards EBPs did not seem to be associated with the ILS and MLQ, further supporting the applicability of the instruments.

Conclusions

The two scales demonstrate good psychometric properties in a Norwegian mental health care setting, which suggests that the MLQ and ILS are valid and reliable tools for measuring leadership in an implementation setting. More research is greatly needed to disentangle the link between perceived leadership and objective measures of successful implementation of EBPs.

Trial registration NSD 690,133, NSD 60,059/3/OOS.

Validation and Use of the Measure of Effective Attributes of Trainers in School-Based Implementation of Proactive Classroom Management Strategies

In-service training is a critical and frequently utilized implementation strategy to support the adoption and delivery of evidence-based practice (EBP) across service settings, but is characteristically ineffective in producing provider behavior changes, particularly when delivered in single exposure didactic events. EBP trainers are in a strategic position to leverage their trainee-perceived characteristics to influence trainees' attitudes, motivation, and intentions to implement, and ultimately increase the likelihood of successful uptake of skills. The purpose of this study was to extend research on the measure of effective attributes of trainers (MEAT) by examining its underlying factor structure and reliability in the context of in-service EBP training for teachers (i.e., structural validity). This study also examined the predictive validity of the MEAT by examining relationships with a measure of teacher intentions to implement EBPs following a standardized training experience (i.e., predictive validity). An exploratory factor analysis (EFA) was employed to determine the latent factors (i.e., subscales of characteristics) that underlie the data. Additionally, a forward selection, stepwise regression was conducted to determine the extent to which trainer attributes could explain variance in intentions to implement. Results indicated that the MEAT was a valid and reliable measure to examine trainer attributes in school settings. Moreover, findings suggested that trainer attributes, particularly those related to trainee perceptions of the trainers' welcoming disposition (i.e., related to trainers' warm, positive temperament and internal character traits), were significantly associated with trainees' intentions to implement the trained upon EBP.

Intervening for sustainable change: Tailoring strategies to align with values and principles of communities

This paper presents a rationale for tailoring implementation strategies within a values-driven implementation approach. Values-driven implementation seeks to organize implementers around clarifying statements of their shared values in ways that harmonize implementation dynamics related to individual and group mental models, relationships among implementers, and the implementation climate. The proposed approach to tailoring strategies is informed by systems theory and emphasizes the need to focus on both tangible events and behaviors, as well deeper patterns, structures, relationships, and mental models, in order to increase the likelihood of sustaining implementation efforts and improving outcomes for people and communities. We offer for consideration three specific sets of context determinants that are under-represented in the implementation literature and that emerge as especially relevant within a systems approach to identifying and successfully tailoring implementation strategies in the implementation setting including relationships, mental models, and implementation climate.

The relationship between first-level leadership and inner-context and implementation outcomes in behavioral health: a scoping review

BACKGROUND

First-level leadership is uniquely positioned to support evidence-based practice (EBP) implementation for behavioral health due to first-level leaders' access to and relationship with service providers. First-level leaders are individuals who directly supervise and manage frontline employees who do not manage others. However, first-level leadership is underrepresented in existing reviews of the impact of leadership on EBP implementation. This review describes the relationship between first-level leadership and implementation determinants and outcomes.

METHODS

A scoping review was performed to synthesize the literature on the relationship between first-level leadership and inner-context and implementation outcomes. A literature search was conducted in PubMed, Eric, PsycINFO, CINAHL, Scopus, and Web of Science. To be eligible, studies had to examine first-level leadership, be conducted in settings providing behavioral health services, and examine the relationship between first-level leadership and an implementation or inner-context outcome. Data extraction and synthesis were performed to describe study characteristics, leader-outcome relationships, and overlap in leadership frameworks.

RESULTS

Twenty-one records met our inclusion criteria. Studies primarily relied on observational designs and were often cross-sectional. Studies more often examined general leadership rather than leadership strategically focused on EBP implementation (i.e., strategic implementation leadership). Our findings suggest that several forms of first-level leadership are inconsistently related to a broad set of implementation determinants, with infrequent examination of specific implementation outcomes. The broad set of implementation determinants studied, limited number of replications, and inconsistent findings have resulted in sparse evidence for any specific leadership-outcome relationship. The greatest accumulation of evidence exists for general leadership's positive relationship with providers' EBP attitudes, most notably in the form of transformational leadership. This was followed by evidence for strategic implementation leadership facilitating general implementation. Our synthesis revealed moderate conceptual overlap of strategic implementation leadership behaviors described in the theory of implementation leadership and theory of middle managers' role in implementation.

CONCLUSIONS

Our findings suggest that first-level leadership may play an important role in shaping implementation determinants and outcomes, but consistent empirical support is sparse and confidence dampened by methodological issues. To advance the field, we need studies that adopt stronger methodological rigor, address the conceptual overlap in leadership frameworks, examine a broader set of implementation outcomes, and examine conditions under which leadership impacts implementation.

TRIAL REGISTRATION

This review was not registered.

Making Implementation Last: The Impact of Training Design on the Sustainability of an Evidence-Based Treatment in a Randomized Controlled Trial

Although advances have been made in facilitating the implementation of evidence-based treatments, little is known about the most effective way to sustain their use over time. The current study examined the sustainability of one evidence-based treatment, Parent-Child Interaction Therapy (PCIT), following a statewide implementation trial testing three training methods: Cascading Model, Learning Collaborative, and Distance Education. Participants included 100 clinicians and 50 administrators from 50 organizations across Pennsylvania. Clinicians and administrators reported on sustainability at 24-months, as measured by the number of clients receiving PCIT and the continued use of the PCIT protocol. Multi-level path analysis was utilized to examine the role of training on sustainability. Clinicians and administrators reported high levels of sustainability at 24-months. Clinicians in the Cascading Model reported greater average PCIT caseloads at 24-months, whereas clinicians in the Learning Collaborative reported greater full use of the PCIT protocol at 24-months. Attending consultation calls was associated with delivering PCIT to fewer families. Implications for the sustainable delivery of PCIT beyond the training year as well as for the broader field of implementation science are discussed.

Strengthening capacity for implementation of evidence-based practices for autism in schools: The roles of implementation climate, school leadership, and fidelity

Understanding the factors that influence the use of evidence-based practices (EBPs) for autism spectrum disorder (ASD) in schools is critical to the selection of effective implementation strategies to support their sustained use. The current study has 2 aims: (a) evaluate the association between school leadership profiles (undifferentiated and optimal) and fidelity of EBP implementation and (b) examine the role of implementation climate as a mediator in this association. Participants included 56 principals, 90 special education teachers, and 133 classroom staff from 66 elementary schools. Participants completed the Multifactor Leadership Questionnaire and Implementation Climate Scale. Teachers and staff reported on intensity (frequency) of EBP delivery, and the research team rated the accuracy (adherence) to the components of the EBP. Schools were required to implement at least 1 of 3 EBPs for ASD (discrete trial training, pivotal response training, or visual supports). Using structural equation modeling, we found that schools with optimal leadership had higher observed ratings of teacher and staff fidelity for pivotal response training accuracy (p < .05), but not for discrete trial training or visual supports. However, this association became nonsignificant with the introduction of implementation climate into the models. Optimal leadership profiles were linked to more positive teacher/staff-reported implementation climate, compared with undifferentiated profiles (p < .01), but found no association between implementation climate and fidelity. Overall, the results of this study indicate that the role of principal leadership in EBP implementation is complex, which has implications for fostering a conducive organizational implementation context in schools. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Otago exercise programme-from evidence to practice: a qualitative study of physiotherapists' perceptions of the importance of organisational factors of leadership, context and culture for knowledge translation in Norway

Background

Falls and fall-related injuries are a major public health problem and an international priority for health services. Despite research showing that evidence-based fall prevention is effective, its translation into practice has been delayed and limited. Although organisational factors such as leadership, culture and context are key factors for implementing evidence-based practice, there is still limited information on whether these factors represent barriers in the Norwegian and international healthcare context. Thus, this study aimed to explore the views of physiotherapists in clinical practice and their leaders’ views on the importance of organisational factors, such as leadership, culture and contextual and human resources, regarding successful knowledge translation of the Otago evidence-based fall programme in a Norwegian community.

Methods

Four in-depth interviews with physiotherapists and a focus group interview with nine physiotherapists and leaders representing local hospitals and municipalities were conducted to collect data. The data were analysed using a thematic analysis.

Results

The analysis yielded an overarching theme: an empowering leader as an anchor is needed for successful knowledge translation of physiotherapists’ and leaders’ views about the role of organisational structure, leadership, culture, financial resources and competence in research-based knowledge, as well as how to enhance the clinical staff’s expertise. Four main themes further elaborated on the overarching theme: (1) multifactor leadership—the importance of reinforcement, knowledge, goals and attention; (2) potential for change in professional roles as shaped by culture, context and type of practice; (3) knowledge translation—the tension between real-life capabilities, optimism and learning; and (4) different types of support—environmental resources and social influences.

Conclusions

This study highlighted the importance of organisational factors in knowledge translation in fall prevention. The findings emphasise the importance of leaders’ role and style in providing a supportive culture and contextual factors during the knowledge translation process. This study provides an understanding of the knowledge translation and sustainability of evidence-based practice and the Otago exercise programme for fall prevention programmes for community-dwelling older adults in Norway.

Supplementary Information

Supplementary information accompanies this paper at 10.1186/s12913-020-05853-8.

Just What I See? Implications of Congruence Between Supervisors' and Employees' Perceptions of Pay Justice for Employees' Work-Related Attitudes and Behaviors

Perceiving a pay system as just has been suggested to be a precondition for individualized pay to have a motivating effect for employees. Supervisors’ enacted justice is central for understanding the effects that pay setting can have on employee attitudes and behavior. Yet, enacted justice has received little research attention, in regard to both organizational justice and pay-related topics. This study examines the effects of employees’ perceived pay justice and supervisors’ enacted justice, as well as the degree of congruence, on employees’ work-related attitudes and behaviors. Questionnaire data from employees (N = 566) matched with data from their pay-setting supervisors (N = 208), employed in a Swedish manufacturing company, were analyzed. Results of polynomial regression with response surface analysis show that employees’ perceptions of pay justice were important for their work-related attitudes and behaviors and that supervisor–employee congruence regarding pay justice was positively related to employees’ attitudes and behavior, particularly when the ratings concerned high levels of justice. The results not only highlight the importance of developing a pay system that is perceived as just by employees but also emphasize the importance of reaching a congruence between supervisors’ and employees’ perceptions of high fairness, as this has positive implications for employees’ attitudes and behaviors.

Understanding the Organizational Implementation Context of Schools: A Qualitative Study of School District Administrators, Principals, and Teachers

Key features of the school environment can have a significant impact on teachers' effective use of evidence-based practices (EBP), yet implementation-specific organizational constructs have rarely been studied in the education sector. This study examined three aspects of the organizational implementation context (implementation leadership, climate, and citizenship behavior), which have been conceptualized and validated in other service settings. Focus groups with central office administrators, principals, and teachers were conducted to understand the applicability and conceptual boundaries of these organizational constructs in schools. Focus group transcripts were coded, and the results indicated both similarities and differences in their conceptualizations of implementation leadership, climate, and citizenship behavior in school. The data indicated that: (1) implementation leadership was largely present in schools with the addition of Distributed Leadership; (2) two implementation climate constructs were most clearly present (i.e., Focus on EBP and Educational Support for EBP) and two additional constructs (i.e., Existing Support to Deliver EBP and Prioritization of EBP) emerged as part of this construct; and (3) implementation citizenship behavior (Helping Others and Keeping Informed) was consistently acknowledged across schools and two new components emerged (i.e., Information Sharing and Observation/Feedback). Recommendations to researchers and community stakeholders are discussed.

Agreement and Discrepancy Between Supervisor and Clinician Alliance: Associations with Clinicians' Perceptions of Psychological Climate and Emotional Exhaustion

Despite increasing interest in supervision as a leverage point for bolstering public mental health services, the potential influence of supervisory alliance on organizations and direct service providers remains understudied, particularly in the context of supporting evidence-based treatment (EBT) use. This study examined agreement and discrepancy between supervisor and clinician ratings of alliance associated with clinicians' perceptions of psychological climate and emotional exhaustion. Results indicated that discrepancies in alliance ratings were common and associated with clinicians' perceptions of psychological climate. These findings have important implications for collaboration among supervisors and clinicians within a community mental health organizational context and the provision of EBTs.

Comparing Agency Leader and Therapist Perspectives on Evidence-Based Practices: Associations with Individual and Organizational Factors in a Mental Health System-Driven Implementation Effort

Agency leaders and therapists are essential stakeholders in implementation of evidence-based practices (EBPs) within publicly-funded mental health services. Little is known about how these stakeholders differ in their perceptions of specific EBPs and which individual and organizational factors differentially influence these perceptions. Within the context of a system-driven implementation of multiple EBPs, survey data from 160 leaders and 720 therapists were examined to assess differences in perceptions of six EBPs. Findings indicated that leaders and therapists have unique perspectives and preferences regarding EBPs that are shaped by distinct sociodemographic and professional characteristics and aspects of organizational functioning.

Concordance Between Administrator and Clinician Ratings of Organizational Culture and Climate

Organizational culture and climate are important determinants of behavioral health service delivery for youth. The Organizational Social Context measure is a well validated assessment of organizational culture and climate that has been developed and extensively used in public sector behavioral health service settings. The degree of concordance between administrators and clinicians in their reports of organizational culture and climate may have implications for research design, inferences, and organizational intervention. However, the extent to which administrators' and clinicians' reports demonstrate concordance is just beginning to garner attention in public behavioral health settings in the United States. We investigated the concordance between 73 administrators (i.e., supervisors, clinical directors, and executive directors) and 247 clinicians in 28 child-serving programs in a public behavioral health system. Findings suggest that administrators, compared to clinicians, reported more positive cultures and climates. Organizational size moderated this relationship such that administrators in small programs (<466 youth clients served annually) provided more congruent reports of culture and climate in contrast to administrators in large programs (≥466 youth clients served annually) who reported more positive cultures and climates than clinicians. We propose a research agenda that examines the effect of concordance between administrators and clinicians on organizational outcomes in public behavioral health service settings.

Discrepancies and Agreement in Perceptions of Implementation Leadership: Associations with Dosage of School-Based Evidence-Based Practices for Children with Autism

Studies demonstrate that discrepancies among leader-follower perceptions of leadership are related to organizational processes that may impact evidence-based practice (EBP) implementation. However, it is unknown whether discrepancies in leadership perceptions also predict EBP use. This study examined the association of principal-staff alignment and discrepancy in perceptions of implementation leadership with the dosage of three Autism-focused school-based EBPs, Discrete Trial Training, Pivotal Response Training (PRT), and Visual Schedules. PRT dosage was higher when principals under-rated their implementation leadership and when it was agreed upon that implementation leadership was low. Findings have implications for leaders support of EBPs implemented in school-based settings.

Leadership profiles associated with the implementation of behavioral health evidence-based practices for autism spectrum disorder in schools

Implementation of evidence-based practice (EBP) for autism spectrum disorder (ASD) in the education system is a public health priority. Leadership is a critical driver of EBP implementation but little is known about the types of leadership behaviors exhibited by school leaders and how this influences the context of EBP implementation, particularly for students with ASD. The objectives of this study were to determine (1) the leadership profiles of principals involved in EBP implementation for students with ASD and (2) how these leadership profiles related to school characteristics and implementation climate. The Exploration, Preparation, Implementation, Sustainment (EPIS) framework was used to guide the design and analysis of this study. Participants (n = 296) included principals, teachers, and classroom support staff. They provided demographic information and completed the Multifactor Leadership Questionnaire and Implementation Climate Scale. Using latent profile analysis, a three-pattern solution was identified: Disengaged (6% of sample), Undifferentiated (23% of sample), and Optimal (71% of sample). Principals in schools with higher proportions of students with an individualized education program were more likely to be classified as Undifferentiated than Optimal. The Optimal group was associated with more positive implementation climate than the Undifferentiated or Disengaged groups. Findings suggest that leadership behaviors rated by principals and their staff involved in implementation of common autism EBPs can be meaningfully clustered into three discernible profiles that are shaped by organizational context and linked to strategic implementation climate. Our study findings have implications for leadership training and service delivery in schools by underscoring the critical nature of school leadership during implementation of EBPs for children with autism and the interplay between specific leadership behaviors and strategic implementation climate.

Individual and organizational factors that affect implementation of evidence-based practices for children with autism in public schools: a cross-sectional observational study

BACKGROUND

Children with autism receive most of their intervention services in public schools, but implementation of evidence-based practices (EBPs) for autism varies. Studies suggest that individual (attitudes) and organizational characteristics (implementation leadership and climate) may influence providers' use of EBPs, but research is relatively limited in this area. This study examined individual and organizational factors associated with implementation of three EBPs-discrete trial training, pivotal response training, and visual schedules-for children with autism in special education classrooms in public elementary schools.

METHODS

Participants included 67 autism support teachers and 85 other classroom staff from 52 public elementary schools in the northeastern United States. Participants reported their attitudes toward EBPs (e.g., intuitive appeal, willingness if required, openness, and divergence), implementation leadership and climate of their school, and the frequency with which they deliver each of three EBPs. Linear regression was used to estimate the association of attitudes about EBPs with organizational characteristics and intensity of EBP use. Demographic covariates with a bivariate association with EBP use significant at p < .20 were entered into the adjusted models.

RESULTS

There were significant findings for only one EBP, discrete trial training. Teachers who reported higher perceived divergence (perceived difference of usual practice with academically developed or research-based practices) between EBPs and current practices used less discrete trial training (f2 = .18), and teachers who reported higher appeal (willingness to adopt EBPs given their intuitive appeal) of EBPs used more discrete trial training (f2 = .22). No organizational factors were significantly associated with implementation with any of the three EBPs.

CONCLUSIONS

Attitudes toward EBPs may affect teachers' decisions to use EBPs; however, implementation leadership and climate did not predict EBP use. Future implementation efforts ought to consider the type of EBP and its fit within the context in terms of the EBP's similarities to and differences from existing practices and programs in the setting. Implementation strategies that target individual attitudes about EBPs may be warranted in public schools.

Attitudes of mental health providers towards adoption of evidence-based interventions: relationship to workplace, staff roles and social and psychological factors at work

Background

Gaining insight into factors influencing the adoption of evidence-based interventions (EBI) is essential to ensuring their sustainability in the mental healthcare setting. This article describes 1) differences between professional staff roles in attitudes towards EBI and 2) individual and organizational predictors of attitudes towards adopting EBI.

Methods

The participants were psychologists and psychiatric nurses (N = 792). Student t-tests were used to investigate group differences of global attitude scores on the Evidence-based Practice Attitude Scale-36 (EBPAS-36). A confirmatory factor analysis (CFA) of the EBPAS-36 measurement model, and a principal component analysis (PCA) of the factor scores were used to obtain attitudinal components for the subsequent hierarchical regression analyses.

Results

Three second-order attitudinal components were retained and named: professional concern, attitudes related to work conditions and requirements, and attitudes related to fit and preferences. Nurses’ global attitudinal scores were more positive than those of psychologists, while clinicians had less positive global attitudinal scores than non-clinicians. Hierarchical regression analysis showed that provider demographic, social and psychological factors in the workplace and staff role predicted attitudes towards adopting EBI, e.g. male gender, older age and working in private practice predicted more negative global attitudes, while working in academia, experiencing social support from colleagues and empowering leadership predicted more positive global attitudes to adopt EBI. The prediction outcomes for the specific attitudinal components are presented, as well.

Conclusion

The findings suggest that implementation efforts may benefit from being tailored to the different needs and values of the affected professionals, including the role of the context they operate within. Implications with a special emphasis on training efforts and organizational development are discussed.

Who Wants Feedback? Effects of Transformational Leadership and Leader-Member Exchange on Mental Health Practitioners' Attitudes Toward Feedback

OBJECTIVE

The purpose of this study was to identify the mechanisms through which different aspects of leadership affect mental health practitioners' attitudes toward supervisory feedback.

METHODS

Data were collected from 363 practitioners nested in 68 treatment teams in public-sector mental health organizations. A multilevel path analysis was conducted to examine the associations of transformational leadership (supervisor's ability to inspire others to follow a course of action) and leader-member exchange (quality of the supervisor-practitioner relationship) with practitioner attitudes toward feedback.

RESULTS

Transformational leadership and leader-member exchange were directly and positively associated with practitioners' attitudes toward feedback. Transformational leadership was also indirectly associated with practitioners' attitudes toward feedback through the quality of supervisor-practitioner relationships.

CONCLUSIONS

Study results contribute to the growing body of evidence suggesting that leaders play a key role in shaping mental health service delivery. Both leadership behavior and high-quality supervisor-practitioner relationships are important in supporting practitioners in delivering evidence-based mental health care. Policymakers, administrators, and researchers should consider an integrative approach when developing leadership training interventions.

Unit Leadership and Climates for Evidence-Based Practice Implementation in Acute Care: A Cross-Sectional Descriptive Study

PURPOSE

The purposes of this study were to (a) describe nurse manager (NM) leadership behaviors for evidence-based practice, NM evidence-based practice competencies, and unit climates for evidence-based practice implementation in acute care, and (b) test for differences in NMs' and staff nurses' (RNs') perceptions.

DESIGN

A multisite cross-sectional design was used to collect data from a sample of 24 NMs and 553 RNs from 24 adult medical-surgical units in seven U.S. community hospitals.

METHODS

Responses were collected using electronic questionnaires, inclusive of the Nurse Manager Evidence-Based Practice Competency Scale (NM only), Implementation Leadership Scale, and Implementation Climate Scale. E-mail reminders and gift card lottery drawings encouraged response. Descriptive statistics described total and subscale scores by role. Differences in perceptions were evaluated using independent t-tests with Bonferroni correction (α = .05).

FINDINGS

23 NMs and 287 RNs responded (95.8% and 51.9% response rates, respectively). NMs reported they were "somewhat competent" in evidence-based practice (M = 1.62 [SD = 0.5]; 0-3 scale). NMs and RNs perceived leadership behaviors (NM: M = 2.73 [SD = 0.46]; RN: M = 2.88 [SD = 0.78]; 0-4 scale) and unit climates for evidence-based practice implementation (NM: M = 2.16 [SD = 0.67]; RN: M = 2.24 [SD = 0.74]; 0-4 scale) as evident to a "moderate extent." RN and NM perceptions differed significantly on the Proactive (p = .01) and Knowledgeable (p < .001) leadership subscales.

CONCLUSIONS

Evidence-based practice competencies and leadership behaviors of NMs, and unit climates for evidence-based practice were modest at best and interventions are needed. To close the research to practice gap, future studies should investigate the interplay between social dynamic context factors and implementation strategies to promote uptake of evidence-based practices.

CLINICAL RELEVANCE

Critical attention is needed to build organizational capacity for evidence-based practices through development of unit leadership and climate for evidence-based practice to accelerate routine use of evidence-based practices for improving care delivery and patient outcomes. The three instruments described herein provide a foundation for nurse leaders to assess these dynamic context factors and design interventions or programs where there is opportunity for improvement.

Community-Based Learning Collaboratives and Participant Reports of Interprofessional Collaboration, Barriers to, and Utilization of Child Trauma Services

Given the high prevalence and severe consequences of child trauma, effective implementation strategies are needed to increase the availability and utilization of evidence-based child trauma services. One promising strategy, the Community-Based Learning Collaborative (CBLC), augments traditional Learning Collaborative activities with a novel set of community-focused strategies. This prospective, observational study examined pre-to post-changes in CBLC participant reports of interprofessional collaboration (IPC), barriers to, and utilization of evidence-based child trauma treatment in their communities. Participants of five CBLCs from a statewide dissemination initiative, comprising 572 child abuse professionals (296 clinicians, 168 brokers, and 108 senior leaders), were surveyed pre-and post-CBLC participation. Results suggested that CBLCs significantly decreased barriers to child trauma treatment and significantly increased IPC and perceived utilization of evidence-based child trauma treatment. Further, changes in barriers partially mediated this relationship. Finally, small to medium differences in participants' reports were detected, such that senior leaders perceived significantly greater IPC than clinicians and brokers did, while brokers perceived significantly greater barriers to child trauma treatment than clinicians and senior leaders did. Collectively, these preliminary findings suggest the CBLC implementation model-which augments traditional Learning Collaborative models with a focus on fostering IPC-can reduce barriers and increase the utilization of evidence-based mental health treatment services.

Self-other agreement of leadership

Purpose

A common component in leadership interventions is the provision of feedback on leadership behaviors. The assumption is that, when there is a discrepancy in this feedback between managers’ and others’ ratings of leadership, this will increase managers’ self-awareness and motivate them to close this gap. The purpose of this paper is to investigate how agreement between managers and their subordinates changes over time as a result of a leadership intervention.

Design/methodology/approach

Questionnaire data were collected from line managers (N=18) and their subordinates (N=640) at pre-intervention, post-intervention and at a six-month follow-up. The managers participated in a leadership intervention that aimed to increase their knowledge and skills related to the leadership behaviors described in the Full-Range Leadership Model. Inter-rater agreement and reliability were calculated to justify aggregating the subordinates’ ratings. The managers and their subordinates were grouped according to three agreement categories: in agreement, managers’ over-rating and managers’ under-rating based on the managers’ views of their leader behaviors in relation to their subordinates’.

Findings

Manager-subordinate agreement on the managers’ leadership increased between pre-intervention and post-intervention but then decreased at the six-month follow-up (17, 61 and 44 percent, respectively). Most managers (n=15) changed agreement categories over time, and only three managers remained in the same agreement category throughout. The subordinates’ mean leadership ratings changed more than the managers’ mean ratings.

Originality/value

This is the first study to explore how manager-subordinate agreement changes when managers participate in a leadership intervention in a health care context. It shows that an intervention that includes upward feedback, by which managers self-rating of their leadership is compared with their subordinates’ ratings, can be an effective way to increase agreement.

Associations among unit leadership and unit climates for implementation in acute care: a cross-sectional study

Background

Nurse managers have a pivotal role in fostering unit climates supportive of implementing evidence-based practices (EBPs) in care delivery. EBP leadership behaviors and competencies of nurse managers and their impact on practice climates are widely overlooked in implementation science. The purpose of this study was to examine the contributions of nurse manager EBP leadership behaviors and nurse manager EBP competencies in explaining unit climates for EBP implementation in adult medical-surgical units.

Methods

A multi-site, multi-unit cross-sectional research design was used to recruit the sample of 24 nurse managers and 553 randomly selected staff nurses from 24 adult medical-surgical units from 7 acute care hospitals in the Northeast and Midwestern USA. Staff nurse perceptions of nurse manager EBP leadership behaviors and unit climates for EBP implementation were measured using the Implementation Leadership Scale and Implementation Climate Scale, respectively. EBP competencies of nurse managers were measured using the Nurse Manager EBP Competency Scale. Participants were emailed a link to an electronic questionnaire and asked to respond within 1 month. The contributions of nurse manager EBP leadership behaviors and competencies in explaining unit climates for EBP implementation were estimated using mixed-effects models controlling for nurse education and years of experience on current unit and accounting for the variability across hospitals and units. Significance level was set at α < .05.

Results

Two hundred sixty-four staff nurses and 22 nurse managers were included in the final sample, representing 22 units in 7 hospitals. Nurse manager EBP leadership behaviors (p < .001) and EBP competency (p = .008) explained 52.4% of marginal variance in unit climate for EBP implementation. Leadership behaviors uniquely explained 45.2% variance. The variance accounted for by the random intercepts for hospitals and units (p < .001) and years of nursing experience in current unit (p < .05) were significant but level of nursing education was not.

Conclusion

Nurse managers are significantly related to unit climates for EBP implementation primarily through their leadership behaviors. Future implementation studies should consider the leadership of nurse managers in creating climates supportive of EBP implementation.

Electronic supplementary material

The online version of this article (10.1186/s13012-018-0753-6) contains supplementary material, which is available to authorized users.

Leading for the long haul: a mixed-method evaluation of the Sustainment Leadership Scale (SLS)

Background

Despite our progress in understanding the organizational context for implementation and specifically the role of leadership in implementation, its role in sustainment has received little attention. This paper took a mixed-method approach to examine leadership during the sustainment phase of the Exploration, Preparation, Implementation, Sustainment (EPIS) framework. Utilizing the Implementation Leadership Scale as a foundation, we sought to develop a short, practical measure of sustainment leadership that can be used for both applied and research purposes.

Methods

Data for this study were collected as a part of a larger mixed-method study of evidence-based intervention, SafeCare®, sustainment. Quantitative data were collected from 157 providers using web-based surveys. Confirmatory factor analysis was used to examine the factor structure of the Sustainment Leadership Scale (SLS). Qualitative data were collected from 95 providers who participated in one of 15 focus groups. A framework approach guided qualitative data analysis. Mixed-method integration was also utilized to examine convergence of quantitative and qualitative findings.

Results

Confirmatory factor analysis supported the a priori higher order factor structure of the SLS with subscales indicating a single higher order sustainment leadership factor. The SLS demonstrated excellent internal consistency reliability. Qualitative analyses offered support for the dimensions of sustainment leadership captured by the quantitative measure, in addition to uncovering a fifth possible factor, available leadership.

Conclusions

This study found qualitative and quantitative support for the pragmatic SLS measure. The SLS can be used for assessing leadership of first-level leaders to understand how staff perceive leadership during sustainment and to suggest areas where leaders could direct more attention in order to increase the likelihood that EBIs are institutionalized into the normal functioning of the organization.

Validation of the Implementation Leadership Scale (ILS) in Substance use Disorder Treatment Organizations

There have been recent calls for pragmatic measures to assess factors that influence evidence-based practice (EBP) implementation processes and outcomes. The Implementation Leadership Scale (ILS) is a brief and efficient measure that can be used for research or organizational development purposes to assess leader behaviors and actions that actively support effective EBP implementation. The ILS was developed and validated in mental health settings. This study validates the ILS factor structure with providers in alcohol and other drug (AOD) use treatment agencies. Participants were 323 service providers working in 72 workgroups from three AOD use treatment agencies. Confirmatory factor analyses and reliability analyses were conducted to examine the psychometric properties of the ILS. Convergent and discriminant validity were also assessed. Confirmatory factor analyses demonstrated good fit to the hypothesized first and second order factor structure. Internal consistency reliability was excellent. Convergent and discriminant validity was supported. The ILS psychometric characteristics, reliability, and validity were supported in AOD use treatment agencies. The ILS is a brief and pragmatic measure that can be used for research and practice to assess leadership for EBP implementation in AOD use treatment agencies.