LOCI: Leadership and Organizational Change for Implementation

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Journal Articles

Below is a collection of articles with more information on implementation and leadership research.

Going Above and Beyond for Implementation: The Development and Validity Testing of the Implementation Citizenship Behavior Scale (ICBS) (2015)
Ehrhart, M. G., Aarons, G. A., Farahnak, L. R.

In conjunction with the recent emphasis on the inner context of organizations during implementation, this study examines organizational citizenship behavior (OCB) and its role in evidence-based practice (EBP) implementation. OCB is characterized by behaviors that go above and beyond what is required for a given job that contribute to greater organizational effectiveness. The goal of this study was to develop and test a measure of implementation citizenship behavior (ICB) or those behaviors that employees perform that go above and beyond what is required in order to support EBP implementation. The participants were 68 supervisors from ten mental health agencies throughout California. Using items developed with past research on OCB, supervisors rated 357 of their subordinates on ICB and implementation success. Additionally, 292 subordinates provided self-ratings of performance, attitudes towards EBPs, work experience, and full-time status. Results indicated that the ICBS is a pragmatic brief measure capable of capturing critical behaviors that employees perform to go beyond what is required to support EBP implementation.

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Leadership and Organizational Change for Implementation (LOCI): A Randomized Mixed Method Pilot Study of a Leadership and Organization Development Intervention for Evidence-Based Practice Implementation (2015)
Aarons, G. A., Ehrhart, M. G., Farahnak, L. R., Hurlburt, M. S.

Leadership is such a vital part in implementation of an innovation in a multitude of settings. Yet there is a need for empirically validated organizational interventions aimed at improving leadership as well as other strategies that facilitate effective evidence-based practice (EBP) implementation. This paper examines the initial feasibility, acceptability, and perceived utility of the Leadership and Organizational Change for Implementation intervention (LOCI). LOCI was developed and tested by a team of investigators and community stakeholders for the purpose of promoting effective leadership for implementing EBPs. Participants were 12 mental health service supervisors and their staff (n=100) from three different child mental health agencies in California. Results from a combination of surveys and focus groups suggest that the LOCI intervention is a feasible and acceptable strategy to be used for improving leadership and organizational strategy to promote effective leadership for EBP implementation.

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Aligning Leadership Across Systems and Organizations to Develop a Strategic Climate for Evidence-Based Practice Implementation (2014)
Aarons, G. A., Ehrhart, M. G., Farahnak, L. R., Sklar, M.

There has been a growing impetus to bridge the gap between basic science discovery, development of evidence-based practices (EBPs), and the availability and delivery of EBPs in order to improve the public health impact of such practices. To capitalize on factors that support implementation and sustainment of EBPs, it is important to consider that health care is delivered within the outer context of public health systems and the inner context of health care organizations and work groups. Leaders play a key role in determining the nature of system and organizational contexts. This article addresses the role of leadership and actions that leaders can take at and across levels in developing a strategic climate for EBP implementation within the outer (i.e., system) and inner (i.e., organization, work group) contexts of health care. Within the framework of Edgar Schein’s “climate embedding mechanisms,” we describe strategies that leaders at the system, organization, and work group levels can consider and apply to develop strategic climates that support the implementation and sustainment of EBP in health care and allied health care settings.

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The Implementation Leadership Scale (ILS): Development of a Brief Measure of Unit Level Implementation Leadership (2014)
Aarons, G. A., Ehrhart, M. G., Farahnak, L. R.

Leadership in healthcare settings is integral to successfully implementing an evidence-based practice (EBP), and yet there are few ways to accurately measure the quality of leadership during an implementation. This paper outlines the conception and development of a brief measure of implantation leadership known as the Implementation Leadership Scale (ILS). Participants were 459 mental health clinicians in 93 outpatient programs in Southern California, and the items were developed through two other NIH studies on leadership training and measure development. Clinicians’ team-level data were used for either an exploratory factor analysis or for a confirmatory factor analysis. Results suggested a 12-item scale with four subscales measuring proactive leadership, knowledgeable leadership, supportive leadership, and perseverant leadership. These subscales would contribute to a single higher order factor of unit level leadership for EBP implementation. These results indicate that the ILS is an efficient, readily available measure of leadership, and it is a promising tool for preparing an organization and its leadership for EBP implementation.

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Assessing the Organizational Context for EBP Implementation: The Development and Validity Testing of the Implementation Climate Scale (ICS) (2014)
Ehrhart, M. G., Aarons, G. A., Farahnak, L. R.

The environment in which evidence-based practices (EBP) are implemented has been established as an important aspect in the success of the implementation. However, there are currently very few methods to measure the implementation climate. The goal of this study was to develop and test a measure of EBP implementation climate that could both assess the many factors associated with effective EBP implementation and be practically utilized by researchers and managers. Participants were 630 clinicians working in 128 work groups in 32 US-based mental health agencies. The items used to measure climate were based on previous implementation literature and on consultation with experts in the field of implementation of EBPs. The results suggested that the Implementation Climate Scale (ICS) was a valid and reliable measure with a structure consisting of six dimensions: 1) focus on EBP, 2) educational support for EBP, 3) recognition for EBP, 4) rewards for EBP, 5) selection for EBP, 6) selection for openness. The ICS is a short and pragmatic measure that captures these six dimensions of the organizational context that employees use to assess how their organization prioritizes and values EBP implementation success.

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Leadership, Innovation Climate, and Attitudes Toward Evidence-Based Practice During a Statewide Implementation (2012)
Aarons, G. A., Sommerfeld, D. H.

Leadership is considered one of the most important factors in changing an organization’s practices, and it is especially crucial within both behavioral health and social service settings. This paper sought to pinpoint how transformational (i.e. charismatic) leaders and their relationships with those that they supervise affect the team’s openness to innovation as well as their attitudes towards adopting evidence-based practice (EBP). Data collection occurred during a statewide implementation of a child neglect reduction intervention, and the participants were 140 case managers (in 30 teams) providing home-based services to families in the child-welfare system. Analyses indicated that transformational leadership was positively associated with innovation climate during the implementation phase which, in turn, was associated with positive attitudes towards EBP adoption. Additionally, the quality of the supervisor-staff relationship was positively associated with innovation climate during the organization’s more stable periods. These results underscore the importance of transformational leadership in promoting a strong innovation climate and positive staff attitudes towards EBPs.

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Advancing a Conceptual Model of Evidence-Based Practice Implementation in Public Service Sectors (2011)
Aarons, G. A., Hurlburt, M., Horwitz, S. M.

Lessons learned about implementation science from business and medical settings are being applied but it is unclear how well they translate to settings with different historical origins and customs (e.g., public mental health, social service, alcohol/drug sectors). The purpose of this paper is to propose a multi-level, four phase model of the implementation process (i.e., Exploration, Adoption/Preparation, Implementation, Sustainment), derived from extant literature, and apply it to public sector services. We highlight features of the model likely to be particularly important in each phase, while considering the outer and inner contexts (i.e., levels) of public sector service systems.

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Evidence-Based Practice Implementation: The Impact of Public versus Private Sector Organization Type on Organizational Support, Provider Attitudes, and Adoption of Evidence-Based Practice (2009)
Aarons, G. A., Sommerfeld, D. H., Walrath-Greene, C. M.

The goal of this study is to extend research on evidence-based practice (EBP) implementation by examining the impact of organizational type (public versus private) and organizational support for EBP on provider attitudes toward EBP and EBP use. Participants were mental health service providers from 17 communities in 16 states in the United States (n = 170). Consistent with our predictions, private agencies provided greater support for EBP implementation, and staff working for private agencies reported more positive attitudes toward adopting EBPs. Organizational support for EBP partially mediated the association of organization type on provider attitudes toward EBP. Organizational support was significantly positively associated with attitudes toward EBP and EBP use in practice.

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The Impact of Evidence-Based Practice Implementation and Fidelity Monitoring on Staff Turnover: Evidence for a Protective Effect (2009)
Aarons, G. A., Sommerfeld, D. H., Hecht, D. B., Silovsky, J. F., Chaffin, M. J.

Staff retention is an ongoing challenge in mental health and community-based service organizations.
Little is known about the impact of evidence-based practice implementation on turnover in the mental health and social service workforce. The present study examined the effect of evidence-based practice implementation and ongoing fidelity monitoring on staff retention in a children’s services system. Analyses revealed greater staff retention where the evidence-based practice was implemented along with ongoing fidelity monitoring presented to staff as supportive consultation. These results should help to allay concerns about staff retention when implementing evidence-based practices where there is good values–innovation fit and when fidelity monitoring is designed as an aid and support to service providers in providing a high standard of care for children and families.

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Implementing Evidence-Based Practice in Community Mental Health Agencies: A Multiple Stakeholder Analysis (2009)
Aarons, G. A., Wells, R. S., Zagursky, K., Fettes, D. L., Palinkas, L. A.

In this article, we sought to identify factors believed to facilitate or hinder evidence-based practice (EBP) implementation in public mental health service systems. Focusing across levels of an entire large public sector mental health service system for youths, we engaged participants from 6 stakeholder groups: county officials, agency directors, program managers, clinical staff, administrative staff, and consumers. Participants generated 105 unique statements identifying implementation barriers and facilitators. Participants rated each statement on importance and changeability (i.e., the degree to which each barrier or facilitator is considered changeable).  Examples include agency and program directors facilitating EBP implementation by supporting staff, actively sharing information with policymakers and administrators about EBP effectiveness and fit with clients’ needs and preferences, and helping clinicians to present and deliver EBPs and address consumer concerns.

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Evidence-Based Practice Implementation and Staff Emotional Exhaustion in Children's Services (2009)
Aarons, G. A., Fettes, D. L., Flores, L. E. Jr., Sommerfeld, D. H.

Understanding the implementation of evidence-based practice (EBP) in community service settings is critical for the successful translation of research to practice. However, we have limited research evidence about the impact of EBP implementation on the mental health and social service workforce. The present study investigates the association of EBP implementation and fidelity monitoring with staff emotional exhaustion in a statewide EBP implementation study. The 21 case-management teams in this study were randomized in a 2 (EBP vs. services as usual [SAU]) by 2 (monitoring vs. no monitoring) design. The EBP in this study was SafeCare, a home-based intervention that aims to reduce child neglect in at-risk families. We found lower emotional exhaustion for staff implementing the EBP but higher emotional exhaustion for staff receiving only fidelity monitoring and providing SAU. Together, these results suggest a potential staff and organizational benefit to EBP implementation and we discuss implications of the findings relative to EBPs and to fidelity monitoring.

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Implementation of Evidence-Based Practice in Child Welfare: Service Provider Perspectives (2007)
Aarons, G. A., Palinkas, L. A.

Implementation of evidence-based practices (EBP) in child welfare is a complex process that is often fraught with unanticipated events, conflicts, and resolutions. In order to better understand the implementation process in the child-welfare system, we interviewed comprehensive home-based services (CHBS) case managers who were actively engaged in implementing an EBP to reduce child neglect in a state youth services system. Six primary factors were identified as critical determinants of EBP implementation: (1) Acceptability of the EBP to the caseworker and to the family, (2) Suitability of the EBP to the needs of the family, (3) Caseworker motivations for using the EBP, (4) Experiences with being trained in the EBP, (5) Extent of organizational support for EBP implementation, and (6) Impact of EBP on process and outcome of services. These factors reflect two broader themes of attitudes toward or assessments of the EBP itself and experiences with learning and delivering the EBP. Eventual implementation is viewed as the consequence of perseverance, experience, and flexibility.

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Organizational Culture and Climate and Mental Health Provider Attitudes toward Evidence-Based Practice (2006)
Aarons, G. A., Sawitzky, A. C.

Mental health provider attitudes toward adopting evidence-based practice (EBP) are associated with organizational context and provider individual differences. Organizational culture and climate are contextual factors that can affect staff acceptance of innovation. This study examined the association of organizational culture and climate with attitudes toward adopting EBP. Participants were 301 public sector mental health service providers from 49 programs providing mental health services for youths and families. Analyses showed that constructive culture was associated with more positive attitudes toward adoption of EBP and poor organizational climates with perceived divergence of usual practice and EBP.

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Transformational and Transactional Leadership: Association with Attitudes toward Evidence-Based Practice (2006)
Aarons, G. A.

Leadership in organizations is important in shaping workers’ perceptions, responses to organizational change, and acceptance of innovations, such as evidence-based practices.  Transformational leadership inspires and motivates followers, whereas transactional leadership is based more on reinforcement and exchanges.  Studies have shown that in youth and family service organizations, mental health providers’ attitudes toward adoption an evidence-based practice are associated with organizational context and individual provider differences.  The purpose of this study was to expand on these findings by examining the association between leadership and mental health providers’ attitudes toward adopting evidence-based practice.  Participants were 303 public-sector mental health service clinicians and case managers from 49 programs who were providing mental health services to children, adolescents, and their families. Data were gathered on providers’ characteristics, attitudes toward evidence-based practices, and perceptions of their supervisors’ leadership behaviors.  Analyses showed that both transformational and transactional leadership were positively associated with providers’ having more positive attitudes toward adoption of evidence-based practice, and transformational leadership was negatively associated with providers’ perception of difference between the providers’ current practice and evidence-based practice. Mental health service organizations may benefit from improving transformational and transactional supervisory leadership skills in preparation for implementing evidence-based practices.

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Mental Health Provider Attitudes toward Adoption of Evidence-Based Practice: The Evidence-Based Practice Attitude Scale (EBPAS) (2004)
Aarons, G. A.

Dissemination and implementation of evidence-based practices (EBPs) into real-world settings represent organizational change that may be limited or facilitated by provider attitudes toward adoption of new treatments, interventions, and practices. A brief measure of mental health provider attitudes toward adoption of EBPs was developed and attitudes were examined in relation to a set of provider individual difference and organizational characteristics.  Participants were 322 public sector clinical service workers from 51 programs providing mental health services to children and adolescents and their families. Four dimensions of attitudes toward adoption of EBPs were identified: (1) intuitive Appeal of EBP, (2) likelihood of adopting EBP given Requirements to do so, (3) Openness to new practices, and (4) perceived Divergence of usual practice with research-based/academically developed interventions. Provider attitudes varied by education level, level of experience, and organizational context. Attitudes toward adoption of EBPs can be reliably measured and vary in relation to individual differences and service context. EBP implementation plans should include consideration of mental health service provider attitudes as a potential aid to improve the process and effectiveness of dissemination efforts.

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Leadership and Procedural Justice Climate as Antecedents of Unit-Level Organizational Citizenship Behavior (2004)
Ehrhart, M.G.

Despite an abundance of research conducted on organizational citizenship behavior (OCB), relatively little is known about unit-level OCB. To investigate the antecedents of unit-level OCB, data were collected from employees of 249 grocery store departments. Structural equation modeling techniques were used to test a model in which procedural justice climate was hypothesized to partially mediate the relationship between leadership behavior (servant-leadership) and unit-level OCB. Models were tested using both employee ratings and manager ratings of unit-level OCB. The results gave general support for the hypotheses, although there were some differences depending on the source of the OCB ratings (supervisor or subordinate), whether the type of department was controlled for, and whether a common method variance factor was included. Overall, the evidence generally supported the association of both servant-leadership and procedural justice climate with unit-level OCB. Building on the current study, a multilevel framework for the study of OCB is presented in conjunction with a discussion of future research directions in four specific areas.

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