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Becan J.E., Knight D.K., Flynn P.M.
Journal of Substance Abuse Treatment: 2012, 42, p. 179–190.
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Message from this large US study is that 'bottom-up' practice improvements in treatment services initiated by counsellors are still strongly influenced by the climate-setting and support offered by an organisation's leadership and ethos, especially how far they foster professional development.
Summary Although innovations may be initiated or mandated by leadership to improve clinical practice, the decision to implement a new intervention in client care is often determined by the individual counsellor. The main focus of this study was on 'bottom-up adoption', the degree to which individuals in an organisation choose to try an innovation, not the degree to which leaders mandate it. In turn this perspective focuses attention on how leaders and organisations foster staff commitment to practice improvements.
In investigating these issues, the study was guided by an influential model of the processes involved in the planning and adoption of innovations developed by Texas Christian University's Institute of Behavioral Research, which has researched these processes in the UK as well as the USA and other countries.
The study was conducted in nine US states and derived its data from 421 counselling staff at 71 outpatient drug-free programmes, a subset of the 92 where more than one staff member had completed a survey on how they saw the treatment environment at their centre. It aimed to tease out what makes counsellors more or less likely to adopt and spread innovations in the treatment of substance use problems, a 'propensity to innovate' tapped by questions such as how often they had adopted new ways of working as a result of training workshops, how often they had encouraged other counsellors to use new ideas they had adopted, and how well clients respond to new ideas and materials.
Other questions looked for qualities in the counsellor which might have influenced their propensity to innovate, such as feeling they influence others in their workplace, flexibly adapt to work demands, feel it is important to and take steps to foster their professional development, and are confident of their abilities.
The study hypothesised that it was by bolstering such qualities in their staff that leaders foster their adoption of new practices, so another set of questions asked about their programme director's leadership qualities such as setting an example, encouraging new ways of looking at the work, and providing well defined performance goals and objectives. It was also expected that the positive influence of these leadership virtues on staff would be greatest when the climate of the organisation as a whole was conducive to change, tapped by questions about the climate at their centre in respect of the clarity and nature of its mission, cohesion among the staff, delegation of authority over their work to staff, adequacy of communications, staff stress, and how receptive the organisation is to change.
In assessing interrelationships between these variables the study adjusted as needed for any influence In the event, all except certification were related to propensity to innovate, such that more experience, having a master's degree, and a higher caseload were related to a stronger propensity. of differing staff experience levels, qualifications, professional certification status, and caseloads, and the possible clustering of similar views among staff at the same centre.
The raw figures showed that all the hypothesised influences on the counsellors' propensities to innovate were indeed related to this propensity. It was also clear that treatment centres differed, tending to generate similar views among staff working there which differed from those elsewhere.
The first link in the proposed causal chain was established when it was found that counsellors keen on professional growth, who feel confident, adapt to new work pressures, and feel they influence others, were indeed more likely These relationships were not significantly different in different centres, ie, they did not depend on where the counsellor worked. to say they tried innovations from training.
Positive leadership qualities also seemed to bolster the propensity of their staff to innovate, a finding which paved the way for establishing whether leadership might exert its effect by affecting the counsellors. On this issue there was evidence that positive leadership did indeed affect counsellors' propensity to innovate by making them keener on professional development. Leadership also partially worked by fostering the other staff attributes of confidence, feeling influential, and feeling that one adapted well to new work pressures.
Lastly was the issue of whether these links depended on the types of organisation the programme director was leading and in which their counsellors worked. In respect of whether it was part of a larger conglomerate or had been approved by accreditation bodies, the answer was no. Instead what seemed influential was how staff saw their workplace in respect of strength of mission, staff cohesion, communications, professional autonomy, not being stressful, and receptiveness to change. The more they perceived these virtues in their workplace, the more influence they felt they had on other staff and the more they valued and practised their own professional development. To the point where leadership qualities were no longer related to professional development, suggesting that organisational climate was the decisive factor. Together leadership and organisational climate accounted for most of the variation between staff in different services in their commitment to professional development and their feelings of being influential. They seemed independent influences on staff; the impact of the leader did not depend on the organisation's climate, nor did the impact of climate depend on leadership.
Findings suggest that organisations, funding agencies, and policy initiatives which promote leadership development, facilitate a climate receptive to change, and foster innovative thinking among staff, are better positioned to promote new treatment methods among clinicians. Results were consistent with the idea that the propensity of staff to adopt new methods is strengthened by:
• an innovative organisation with creative leadership; and
• change-oriented staff attributes (ie, confidence, influence on others, professional development, and adaptability), and
• that each strengthens the change-promoting impact of the other.
In other words, leaders do have a cascading impact on their staff in ways other than through mandate, findings which highlight the importance of training leaders to be supportive of innovation and to construct an environment which bolsters open thinking among staff.
More detailed findings suggest that strong, positive leaders are not in themselves enough to maximise innovation adoption; they need to instil confidence among their employees in their own abilities, a desire to influence organisational improvement, and adaptability to new work objectives. Most of all, it seems essential that leaders use their influence (including support of new interventions and establishing a clear and forward-thinking mission) to promote a commitment to professional development among their staff, without which even the best leaders will find staff less amenable to initiating change.
How the organisation is perceived is also influential. When the climate is seen as receptive to change as well as when there is supportive and innovative leadership, counsellors perceive more opportunities for professional development. Also, counsellors working in conducive environments feel they have more influence on others in their workplace and are more confident and prepared to adapt, so can adopt and spread new practices.
The study does however have some limitations. All the influences it tested were assessed at the same time and within the same assessment, precluding the establishment of whether proposed causes actually did come before their hypothesised effects, and it sampled only non-residential services. There was no information of what types of evidence-based practices were implemented by staff.
commentary With the benefit of a large and diverse (but entirely non-residential) set of organisations to draw its data from, and a well worked out model of change to help make sense of that data, from the featured study emerges a persuasive set of often mutually reinforcing links between organisational climate, leadership, and staff attitudes, which interact to influence whether staff feel they have the motivation, 'permission', and confidence to initiate practice changes for themselves and promote these to their colleagues, and perhaps too the clarity of mission to sense what direction change should take. However, these variables were all assessed on the basis of the accounts given by counsellors rather than independently verified; more below on this methodological limitation.
All main variables tested by the study were assessed on the basis of the accounts given by counsellors in response to research surveys. There was, for example, no independent verification of whether when they said they had adopted new ways of working and encouraged others to do the same, they actually had, nor whether they truly were as adaptable and keen on professional development as they claimed, nor that their perceptions of their services and programme directors were valid. This leaves the study vulnerable to a 'halo effect' – staff who rate themselves highly on one variable also rating themselves highly on another and seeing their leaders and organisations through the same possibly rose-tinted spectacles. Arguing that this is not the entire explanation of the findings, is that in most cases ratings from staff at the same service were more similar to each other than to those of staff elsewhere, and that the strength of the relationships varied to the degree that some were (when other factors had been taken to account) not statistically significant; there was more to the findings than just the degree of rosiness of each individual's spectacles as they completed the survey.
Evidence that the kind of organisations which in the featured study fostered innovation adoption by their staff are also found engaging by clients comes from a British study by the originators of the model on which the featured study was based. They used some of the same questionnaires to investigate 44 substance use treatment services in and around Manchester, Birmingham, and Wolverhampton. Each took a 'snapshot' of their clients using the US centre's CEST (Client Evaluation of Self and Treatment) forms for the clients, which asked them to rate themselves on statements representing their motivation and readiness for treatment, psychological and social functioning, and engagement with treatment. At the same time, counsellors at the services completed ORC (Organizational Readiness for Change) forms also used in the featured study, assessing their perceptions of the service they worked for and of their own professional functioning and needs. This work, which represents the most wide-ranging investigation of the organisational health of British treatment services to date, found clients engaged best when services fostered communication, participation and trust among staff, had a clear mission, but were open to new ideas and practices.
Such findings should come as no surprise, because studies of the implementation of new treatment practices have highlighted the degree of commitment needed by the whole organisation if an initial training experience is actually to result in the desired changes at the clinical front line. For this to happen care has to be taken that the innovation fits with the organisation's and its clients' needs, and that training is reinforced by ongoing supervision and coaching, if possible based on feedback from taped sessions, and opportunities to discuss implementation barriers.
Studies are lacking on whether it is possible deliberately to engineer a conducive climate and leadership along the dimensions measured by the featured study in ways which improve treatment engagement or outcomes. Such studies are rare probably because change along dimensions like mutual trust among staff, or willingness to listen to their suggestions, cannot simply be introduced by researchers and then studied. However, at least one study has shown that feedback of scores from the ORC organisational health scale used in the featured study can motivate less well functioning agencies to engage in an improvement programme. Agencies which scored as less open Lower scores on cohesion, communication, and openness to change were associated with a higher likelihood of further work in making improvements in the area(s) identified in an assessment and training workshop designed to improve organisational functioning. to change and staff suggestions – the ones which would normally be least likely to engage in a change process – were the ones most likely to commit to change The study was unable to report whether they actually followed through on this commitment. when faced with the evidence of their shortcomings.
For more on leadership and organisational health in treatment services see this Findings hot topic.
Last revised 17 May 2013. First uploaded 14 May 2013
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