U2A1 & U2D1 - Advanced Searching Teachniques - please follow all instructions and read all attached documents. Due Sunday by 9pm. CST. My Field is Public Service Leadership

PSYCHIATRIC SERVICES ♦ ps.psychiatryonline.org ♦ August 2006 Vol. 57 No. 811116622

There is growing momentumand pressure to move evi-dence-based mental health in- terventions into real-world practice settings (1–5). Most of these practice settings involve a relationship be- tween a clinical or case management supervisor and practitioners who pro- vide services. Often in community settings the clinical supervisor also supervises work activities, including conducting performance appraisals

and other human resource functions. Leadership is important in these ac- tivities. Recent work has also demon- strated that mental health service providers’ attitudes toward adopting evidence-based practice are associat- ed with organizational context (for ex- ample, structure and policies) and in- dividual provider differences (for ex- ample, education and experience) (6,7). Yet, although leadership is held to influence the adoption of innova-

tions, such as evidence-based prac- tices (8), there has been little re- search on the association between leadership of the mental health su- pervisor and staff attitudes toward adopting evidence-based practice. However, some more general leader- ship studies have been conducted.

Leadership research is pervasive in the organizational literature, and studies in mental health services sug- gest that leadership is important for both for the organizational process and for consumer satisfaction and outcomes (9–11). Glisson and Durick (11) found that higher levels of posi- tive leadership in human service or- ganizations were associated with higher levels of organizational com- mitment. In a study on mental health services for youths, organizational cli- mate mediated the association of leadership and working alliance (12). Higher levels of positive leadership were associated with a more positive organizational climate, which was in turn associated with higher positive clinician ratings of working alliance. Thus there are links between leader- ship, organizational and clinical process, and consumer satisfaction and outcome. However, research is needed that examines the effect of leadership on attitudes toward adopt- ing evidence-based practices in men- tal health service settings.

Transformational and transactional leadership are two well-studied lead- ership styles that have been assessed by the Multifactor Leadership Ques- tionnaire (MLQ) (9,13,14). Transfor- mational and transactional leadership span both cultural and organizational boundaries (15) and have been as- sessed and validated in numerous

Transformational and Transactional Leadership: Association With Attitudes Toward Evidence-Based Practice GGrreeggoorryy AA.. AAaarroonnss,, PPhh..DD..

Dr. Aarons is affiliated with the Child and Adolescent Services Research Center, 3020 Children’s Way, MC-5033, San Diego, CA 92123 (e-mail: [email protected]). He is also with the Department of Psychiatry, University of California, San Diego.

Objective: Leadership in organizations is important in shaping workers’ perceptions, responses to organizational change, and acceptance of in- novations, such as evidence-based practices. Transformational leader- ship 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’ atti- tudes toward adopting an evidence-based practice are associated with organizational context and individual provider differences. The purpose of this study was to expand these findings by examining the association between leadership and mental health providers’ attitudes toward adopting evidence-based practice. Methods: Participants were 303 pub- lic-sector mental health service clinicians and case managers from 49 programs who were providing mental health services to children, ado- lescents, and their families. Data were gathered on providers’ charac- teristics, attitudes toward evidence-based practices, and perceptions of their supervisors’ leadership behaviors. Zero-order correlations and multilevel regression analyses were conducted that controlled for effects of service providers’ characteristics. Results: Both transformational and transactional leadership were positively associated with providers’ hav- ing more positive attitudes toward adoption of evidence-based practice, and transformational leadership was negatively associated with providers’ perception of difference between the providers’ current prac- tice and evidence-based practice. Conclusions: Mental health service or- ganizations may benefit from improving transformational and transac- tional supervisory leadership skills in preparation for implementing evi- dence-based practices. (Psychiatric Services 57:1162–1169, 2006)

aar.qxd 7/20/2006 10:01 AM Page 1162

studies (16–26). Leadership studies with the MLQ have also been con- ducted in mental health and other public-sector organizations (9,14,27– 29), health care settings (30), and service settings. A given leader may exhibit varying degrees of both trans- formational and transactional leader- ship. The styles are not mutually ex- clusive, and some combination of both may enhance effective leadership.

Transformational leadership is akin to charismatic or visionary leadership (31). Transformational leaders inspire and motivate followers (32,33) in ways that go beyond exchanges and rewards. Transformational leadership operates especially well in close su- pervisory relationships, compared with more distant relationships (23), and closer supervision is often more typical in mental health settings. This close relationship may be typical of a supervisor-supervisee relationship and is also captured in the notion of “first- level leaders” (34), who are thought to be important because of their func- tional proximity to supervisees in an organizational setting. Transforma- tional leadership is thought to in- crease the follower’s intrinsic motiva- tion (35) through the expression of the value and importance of the leader’s goals (31,36).

In contrast, transactional leadership is based more on “exchanges” between the leader and follower, in which fol- lowers are rewarded for meeting spe- cific goals or performance criteria (37–40). Rewards and positive rein- forcement are provided or mediated by the leader. Thus transactional lead- ership is more practical in nature be- cause of its emphasis on meeting spe- cific targets or objectives (41–43). An effective transactional leader is able to recognize and reward followers’ ac- complishments in a timely way. How- ever, subordinates of transactional leaders are not necessarily expected to think innovatively and may be moni- tored on the basis of predetermined criteria. Poor transactional leaders may be less likely to anticipate prob- lems and to intervene before problems come to the fore, whereas more effec- tive transactional leaders take appro- priate action in a timely manner (39).

A transactional leadership style is appropriate in many settings and may

support adherence to practice stan- dards but not necessarily openness to innovation. A transformational lead- ership style creates a vision and in- spires subordinates to strive beyond required expectations, whereas trans- actional leadership focuses more on extrinsic motivation for the perform- ance of job tasks (39,44). Thus it is likely that transformational leader- ship would influence attitudes by in- spiring acceptance of innovation through the development of enthusi- asm, trust, and openness, whereas transactional leadership would lead to acceptance of innovation through re- inforcement and reward.

In summary, leadership is important to consider in relation to acceptance of innovations and to work attitudes, per- ceptions, behavior, service quality, and client outcomes. Because leadership is associated with organizational and staff performance, we propose that it is like- ly to influence mental health providers’ attitudes toward adoption of evidence- based practices. Although leadership is prominent in our model of implemen- tation of evidence-based practices (7), few studies have examined transforma- tional and transactional leadership and mental health providers’ attitudes. Fi- nally, no studies have examined leader- ship and attitudes toward adopting evi- dence-based practices in mental health services for youths.

In understanding organizational predictors of attitudes toward evi- dence-based practices, it is also im- portant to consider and control for individual-level variables, such as providers’ demographic characteris- tics. A recent review suggests that de- mographic characteristics and atti- tudes can be influential in the will- ingness to adopt and implement an innovation (45). For example, recep- tivity to change can be an important determinant of innovation success (46,47). Rogers (8) asserted that hav- ing more formal education, as well as favorable attitudes toward change and science, are associated with in- creased adoption of an innovation. Educational attainment is positively associated with endorsement of evi- dence-based treatment services, adoption of innovations, and atti- tudes toward adoption of evidence- based practices (6,48–50). In special-

ty mental health clinics, compared with professional providers, interns report having a more positive atti- tude toward using evidence-based as- sessment protocols (51) and toward adopting evidence-based practices (6). Because there is a link between organizational characteristics, indi- vidual differences, and attitudes to- ward work, these factors should be included in studies of attitudes to- ward evidence-based practice.

The purpose of the study presented here was to examine the association of transformational and transactional su- pervisor leadership with service pro- viders’ attitudes toward evidence- based practices. We hypothesized that more positive transformational leader- ship would be associated with more positive attitudes toward implement- ing evidence-based practices, as evi- denced by greater openness, greater sense of appeal of evidence-based practices, and lower perceived diver- gence of usual practice with evidence- based practices. We also hypothesized that transactional leadership would be associated with more positive attitudes toward adopting evidence-based prac- tice, given requirements to do so.

Methods Participants Participants were providers of mental health clinical and case management services who took part in a larger study of organizational issues affect- ing the provision of mental health services to children, adolescents, and their families in San Diego County, California (6). Organizational and in- dividual participation rates were high (94 and 96 percent, respectively). Data were collected between No- vember 21, 2000, and September 19, 2001. Of the 322 providers in the larger study, 19 participants (5.9 per- cent) were missing data on at least one of the variables in the set of analyses used in this study, resulting in a final sample of 303 providers working in 49 publicly funded mental health programs for youths.

Table 1 shows demographic charac- teristics for individual-level nominal and continuous variables in the study. A total of 245 respondents (81 per- cent) were full-time employees. Pri- mary disciplines included marriage

PSYCHIATRIC SERVICES ♦ ps.psychiatryonline.org ♦ August 2006 Vol. 57 No. 8 11116633

aar.qxd 7/20/2006 10:01 AM Page 1163

and family therapy (103 participants, or 34 percent), social work (99 partic- ipants, or 33 percent), psychology (65 participants, or 21 percent), psychia- try (five participants, or 2 percent), and “other” (for example, criminolo- gy, drug rehabilitation, education, or public health; 31 participants, or 10 percent). There were fewer interns than professional staff in the service system (26 percent compared with 74 percent). The mean±SD age of re- spondents was 35.7±10.5 years. Sev- enty-six percent were female. Sixty- five percent were Caucasian, 15 per- cent were Hispanic, 7 percent were African American, 6 percent were Asian or Pacific Islander, 1 percent were Native American, and 7 percent were another race or ethnicity. (Per- centages total more than 100 percent because of rounding.)

Measures Provider survey. The provider survey incorporated questions about provi- ders’ demographic characteristics, in- cluding age, sex, education level, pro- fessional status (intern or profession- al), and job tenure (time working in

the present employment setting) (6). Providers’ education level was as- sessed with ordered categories from low to high: attainment of some col- lege, college graduate, some graduate work, master’s degree, and doctoral degree (Ph.D., M.D., or equivalent). Intern status indicated whether the respondent was an intern or an em- ployed professional. Professional sta- tus was coded as 0 for staff and as 1 for interns.

Attitudes toward evidence-based practice. The Evidence-Based Prac- tice Attitude Scale (EBPAS) (6) was used to assess mental health providers’ attitudes toward evidence-based prac- tice. The EBPAS is a brief, 15-item measure with four subscales assessing attitudes toward adoption of evidence- based practices. The four EBPAS sub- scales represent four theoretically de- rived dimensions of attitudes toward adoption of evidence-based practices: appeal, requirements, openness, and divergence. Total scores on the EBPAS were also calculated.

The score on the appeal subscale represents the extent to which the provider would adopt an evidence- based practice if it were intuitively appealing, could be used correctly, or was being used by colleagues who were happy with it. The score on the requirements subscale assesses the extent to which the provider would adopt an evidence-based practice if it was required by an agency, supervi- sor, or state. The score on the open- ness subscale assesses the extent to which the provider is generally open to trying new interventions and would be willing to try or use evidence- based practices. The score on the di- vergence subscale assesses the extent to which the provider perceives evi- dence-based practices as not clinical- ly useful and less important than clin- ical experience. The total score on the EBPAS represents one’s global atti- tude toward adoption of evidence- based practices. The overall Cron- bach’s alpha reliability for the EBPAS was good (α=.77), and subscale al- phas ranged from .90 to .59. The EBPAS validity is supported by asso- ciations of EBPAS scales with both individual provider-level attributes and organizational characteristics (6,48). All responses for the EBPAS

were scored on a 5-point scale, rang- ing from 0, not at all, to 4, to a very great extent.

Leadership. The MLQ 45-item Form 5X was used to assess the providers’ perceptions of supervisors’ transformational and transactional leadership behaviors (52). Transfor- mational leadership was assessed with four subscales of idealized influence (eight items, α=.87), inspirational motivation (four items, α=.91), intel- lectual stimulation (four items, α= .90), and individual consideration (four items, α=.90). Transactional leadership was assessed with four subscales detailing leadership styles, including contingent reward (four items, α=.87), laissez-faire (four items, α=.83), active management by exception (four items, α=.74), and pas- sive management by exception (four items, α=.82). Providers were asked to judge the extent to which their im- mediate supervisor engaged in specif- ic behaviors measured by the MLQ. Each behavior was rated on a 5-point scale ranging from 0, not at all, to 4, to a very great extent.

Survey procedure A program manager was contacted at each program, and the study was de- scribed to him or her in detail. Per- mission was sought to survey service providers who worked directly with youths and families. For participating programs, providers’ survey sessions were scheduled at the program site at a time designated by the program manager. Surveys were administered to groups of providers. The project coordinator or a trained research as- sistant administered providers’ sur- veys and was available during the sur- vey session to answer any questions that arose. A few surveys were left for completion for providers who did not attend the survey sessions. Such sur- veys were either mailed back in a prepaid envelope or picked up by a research assistant. Participants re- ceived a verbal and written descrip- tion of the study, and informed con- sent was obtained before the survey. Participation in the study was volun- tary, and all participant responses were confidential. This study was ap- proved by the appropriate institu- tional review boards.

PSYCHIATRIC SERVICES ♦ ps.psychiatryonline.org ♦ August 2006 Vol. 57 No. 811116644

TTaabbllee 11

Characteristics of 303 providers working in 49 publicly funded mental health programs for youths

Variable N %

Gender Male 71 23 Female 232 77

Staff Professional 224 74 Intern 79 26

Education level Some college 10 3 Bachelor’s degree 57 19 Some graduate

school 32 11 Master’s degree 175 58 Doctoral degree 28 9

Race or ethnicity Caucasian 197 65 Latino 44 15 African American 20 7 Asian or Pacific

Islander 19 6 Native American 2 1 Other 21 7

Age (M±SD) 35.7±10.49 Job tenure (M±SD

years) 1.97±3.17

aar.qxd 7/20/2006 10:01 AM Page 1164

Analyses Pearson product-moment correlation analyses were first conducted to ex- amine associations of transformation- al and transactional leadership and in- dividual-level covariates with the de- pendent variables—that is, EBPAS scores representing attitudes toward evidence-based practices. Next, re- gression analyses were conducted in order to examine the associations of leadership with scores on each of the four EBPAS subscales and total scores on the scale while the analyses controlled for the effects of individual provider characteristics. Because pro- viders were nested within mental health programs, resulting in poten- tial dependency of responses within program, multilevel analyses were conducted to control for the effects of the nested data structure (53–55). All regression analyses were conducted by using the Mplus analytic software, which accounted for the nested data structure (56). Because hypotheses were directional, one-tailed signifi- cance tests were used.

Results As shown in Table 2, correlation analyses showed a pattern of results supporting the hypothesis that ratings of higher levels of positive leadership would be associated with more posi-

tive attitudes toward evidence-based practice. Specifically, transformation- al leadership was significantly posi- tively associated with scores on the EBPAS subscales of appeal, open- ness, and requirements and EBPAS total scores. Transactional leadership was significantly positively associated with scores on the EBPAS subscales of openness and requirements and EBPAS total scores. Next, a regres- sion analysis was performed for each EBPAS subscale and one for the overall scale.

All regression analysis results are shown in Table 3. Neither a transfor- mational nor a transactional leader- ship style was significantly associated with scores on the EBPAS appeal subscale. In regard to provider char- acteristics, higher scores on the ap- peal subscale were associated with being female, having a higher educa- tional attainment, and being an in- tern. Predictors accounted for 7.4 percent of the variance in scores on the appeal subscale.

Transactional leadership was signifi- cantly positively associated with scores on the EBPAS openness subscale. This indicates that providers who reported that immediate supervisors exhibited more transactional leadership behav- iors endorsed greater general openness toward adoption of evidence-based

practices. Job tenure was significantly negatively associated with scores on the openness subscale, indicating that providers who worked at their program for longer periods scored lower on the openness subscale. Predictors account- ed for 14.0 percent of the variance in scores on the openness subscale.

Transformational leadership was significantly positively associated with scores on the requirements subscale. This finding indicates that providers who worked with supervisors who they rated higher on transformational leadership were more willing to adopt evidence-based practices if required to do so. There was also a marginal ef- fect (p=.081) suggesting that transac- tional leadership was associated high- er scores on the requirements sub- scale. Predictors accounted for 7.7 percent of the variance in EBPAS to- tal scores.

As hypothesized, transformational leadership was negatively associated with the scores on the EBPAS diver- gence subscale. This finding indicates that providers who worked with super- visors who exhibited more transforma- tional leadership behaviors were less likely to perceive a gap between their current practices and evidence-based practices. Predictors accounted for 5.1 percent of the variance in scores on the divergence subscale.

PSYCHIATRIC SERVICES ♦ ps.psychiatryonline.org ♦ August 2006 Vol. 57 No. 8 11116655

TTaabbllee 22

Correlation matrix of demographic characteristic covariates, leadership, and scores on the Evidence-Based Practice Attitude Scale (EBPAS) of 303 providers working in 49 publicly funded mental health programs for youths

Transform- Transac- Educa- Job ational tional Open- Require- Diver-

Variable Age Sex tion Intern tenure leadership leadership Appeal ness ments gence

Age Sex –.186∗∗∗ Education .383∗∗∗ .037 Intern –.148∗∗ .094 .146∗ Job tenure .430∗∗∗ –.051 .155∗∗ –.165∗∗ Transformational

leadership –.137∗ .001 –.043 .131∗ –.135∗ Transactional

leadership –.053 –.125 –.157∗∗ .099 –.040 .545∗∗∗ Appeal .002 .125∗ .153∗∗ .141∗ –.054 .130∗ .109 Openness –.026 .030 –.063 .072 –.156∗∗ .238∗∗∗ .327∗∗∗ .445∗∗∗ Requirements –.09 .017 –.084 .105 –.074 .233∗∗∗ .218∗∗∗ .329∗∗∗ .195∗∗∗ Divergence .161∗∗ –.035 .014 –.113∗ .128∗ –.108 .019 –.074 .045 –.179∗∗ EBPAS total score –.109 .760 –.016 .168∗∗ –.161∗∗ .288∗∗∗ .264∗∗∗ .710∗∗∗ .631∗∗∗ .723∗∗∗ –.449∗∗∗

∗p<.05 ∗∗p<.01

∗∗∗p<.001

aar.qxd 7/20/2006 10:01 AM Page 1165

Finally, both transformational and transactional leadership were posi- tively associated with total scores on the EBPAS. This finding supports the proposed hypothesis and indicates that providers who rated their super- visor higher on transformational and transactional leadership were more open to adopting evidence-based practices. In regard to demographic variables, being an intern was posi- tively associated and job tenure was negatively associated with more posi- tive attitudes toward evidence-based practices. Predictors accounted for 13.4 percent of the variance in total scores on the EBPAS.

Discussion The main finding of this study is that more positive leadership ratings were associated with more positive attitudes toward adopting evidence- based practice. This is congruent with the notion that leadership is im- portant in the adoption of innova- tions across a range of organizational contexts and technologies (8,57,58). However, across all EBPAS sub- scales and the total scale on the EBPAS, predictors accounted for about 5 to 14 percent of variance in subscale and total scores. This sug- gests that although leadership is as- sociated with providers’ attitudes to- ward evidence-based practices, addi- tional factors should be considered.

In the study presented here both transformational and transactional leadership were associated with atti- tudes toward adoption of evidence- based practices.

Transformational leadership was positively associated with scores on the requirement subscale and total scores on the EBPAS scale and nega- tively associated with scores on the di- vergence subscale. It is likely that su- pervisors who exhibit more positive transformational leadership behav- iors engender attitudes in subordi- nates that would lead subordinates to greater openness to adopting new technologies or practices. This find- ing is clearly in keeping with the def- inition of transformational leadership as inspiring commitment to and en- thusiasm for the leader and willing- ness to follow the leader’s vision. Con- sistent with this definition is the find- ing that transformational leadership was associated with the total EBPAS score, indicating that inspirational and motivational leadership may en- gender open attitudes.

Also of interest is the finding that higher transformational leadership was associated with lower perceived divergence of evidence-based prac- tices and usual practices. It is likely that this finding indicates a general distrust of change and practices that are perceived as different from usual care where leadership is suboptimal.

These findings suggest that having a positively perceived local opinion leader to introduce and guide change in practice may facilitate receptivity to change in providers’ behavior (59). Consistent with the above findings, transactional leadership was positive- ly associated with scores on both the openness subscale and the total EBPAS scale. This suggests that lead- ership styles that appropriately rein- force positive work behaviors may lead to a greater sense of trust in the supervisor-supervisee relationship and lead to greater openness toward adopting evidence-based practices.

Some limitations of this work should be noted. First, this study as- sessed providers’ attitudes rather than actual uptake of evidence-based prac- tices. There are a number of factors likely to influence not only attitudes toward evidence-based practices but also actual implementation. Indeed, a leader’s attitude toward evidence- based practice may influence staff at- titudes, and leaders’ attitudes were not assessed in this study—instead, providers rated their perception of their supervisors’ leadership behav- iors. Second, this is a cohort study, and although it is intuitively appealing to suggest that supervisor leadership precedes staff attitudes, such an infer- ence is not warranted on the basis of the correlational nature of this study.

Third, this study involved public-

PSYCHIATRIC SERVICES ♦ ps.psychiatryonline.org ♦ August 2006 Vol. 57 No. 811116666

TTaabbllee 33

Multilevel regression analysis of the association of transformational and transactional leadership with the subscales of the Evidence-Based Practice Attitude Scale among 303 providers working in 49 publicly funded mental health programs for youths

Appeal Openness Requirements Divergence Total

Variable Coef.a SE z Coef.a SE z Coef.a SE z Coef.a SE z Coef.a SE z

Age .001 .004 .167 .007 .005 1.557 –.001 .005 –.264 .008 .005 1.633 .000 .003 –.146 Sex .193 .074 2.605∗∗ .133 .089 1.498 .047 .137 .344 .019 .077 .245 .088 .065 1.346 Education .104 .044 2.362∗∗ –.024 .041 –.574 –.052 .052 –1.004 –.013 .041 –.318 .01 .032 .318 Intern .122 .069 1.750∗ .033 .092 .362 .148 .137 1.081 –.119 .086 –1.383 .106 .064 1.653∗ Job tenure –.011 .009 –1.190 –.039 .013 –3.030∗∗ –.005 .015 –.355 .011 .016 .694 –.016 .008 –1.984∗ Transforma-

tional leadership .052 .047 1.104 .063 .059 1.063 .164 .073 2.234∗ –.112 .051 –2.189∗ .098 .034 2.854∗∗

Transactional leadership .115 .080 1.438 .360 .075 4.817∗∗ .174 .124 1.400 .116 .093 1.247 .133 .072 1.835∗

a Unstandardized regression coefficient ∗p<.05

∗∗p<.01

aar.qxd 7/20/2006 10:01 AM Page 1166

sector mental health providers, and results may not generalize to other contexts or provider groups. Howev- er, this concern is somewhat mitigat- ed to the extent that the findings pre- sented here are consistent with the literature on leadership and organiza- tional change. Fourth, five regression models were estimated, and thus in- flation of type I error rates could be a factor in this set of analyses. Fifth, providers’ ratings of their supervisors’ leadership was assessed in the study presented here. However, other orga- nizational variables may also be relat- ed to providers’ attitudes toward evi- dence-based practices (48). Finally, the focus of leadership was not as- sessed. That is, it is unknown in the study presented here the degree to which supervisors promoted the use of evidence-based practices. This leaves us with findings regarding gen- eral, rather than specific, effects of transformational leadership.

Further studies are needed to ex- amine the extent to which supervisors’ transformational and transactional leadership that was focused specifical- ly on improving attitudes and imple- mentation of evidence-based prac- tices would lead to greater, lesser, or different associations with providers’ attitudes and ultimately, with evi- dence-based practice implementation fidelity and client outcomes.

One of the strengths of the study presented here is that it focused on real-world mental health service providers working in community- based, publicly funded mental health programs. In that respect, this work differs from studies of manualized in- terventions focusing on more tradi- tional psychotherapy practices with doctoral-level clinicians (60,61). In the public behavioral health care sys- tem, a majority of providers in the workforce in community settings across the United States do not have doctoral-level educations, and these essential providers will likely be agents of widespread delivery of evi- dence-based interventions. Thus, al- though this study took place in one large county, the results are likely to generalize to other similar settings. Additional research is needed in or- der to determine if these findings can be replicated.

This study also adds to the evidence base for the construct validity of the EBPAS. Previous work provided pre- liminary validation of the EBPAS; our findings support the notion that atti- tudes may be affected not only by the context within which providers deliver mental health services but also by the leader-staff interactions and ex- changes in the workplace that can af- fect job performance and organiza- tional citizenship (62–64). This sug- gests that leadership development tar- geted at improving the organizational change process could be considered before or concurrent with evidence- based practice implementation.

Providers in the study presented here were predominantly female, and a majority of public-sector providers of youth mental health services are female. Leadership and subordinate perceptions and relationships may be affected by the sex of the leader or follower. For example, gender affects leadership style, and effective leader- ship involves a balance of positive feminine and masculine characteris- tics (65). Female leaders may also be rated higher on interpersonal aspects of transformational leadership (66). It appears that in understanding leader- ship effects, gender of the leader and follower should be considered, but the extent to which these factors are at play in mental health services and evidence-based practice implementa- tion requires further study.

As with providers in other types of services, those who provide youth and family services are often highly com- mitted to their work and clients. Leadership is important in work in- teractions and in shaping organiza- tional culture to support change and innovation (67). Attitudes toward adopting evidence-based practice may be influenced to the extent that leaders are effective in communicat- ing and getting support for a vision that includes the adoption and use of evidence-based practices. Transac- tional leadership may also help in re- warding and reinforcing behaviors that support the vision.

Working in the public sector brings special challenges for organizations implementing evidence-based prac- tices. For example, the need for ob- taining or renewing contracts and se-

curing funding is an ongoing concern. At the local level, implementing evi- dence-based practices within an exist- ing contract may mean renegotiating statements of work and defining what services can be reimbursed. National reimbursement policies may not be aligned with the provision of some ev- idence-based practices. These and other related concerns can lead to challenges for leaders in communi- cating how a vision of improved or changed services fits, or does not fit, with the day-to-day roles, duties, and tasks fulfilled by providers. Stronger leadership should help to mitigate some of the stresses of day-to-day op- eration of services and improve man- agers’ ability to lead change.

Particular attention should be paid to the perceptions and attitudes of public-sector providers and their su- pervisors. There have been recent calls for renewed attention to work- force development (68,69). More ef- fective leadership is one mechanism by which first-level leaders (34), such as program managers, can work with their staff to improve the workplace and the ability of programs to re- spond to the need for change in per- spective and process that accompa- nies implementation of evidence- based practices. It is these first-level leaders who generally have the re- sponsibility for managing and moni- toring change. Attention to the rela- tionships between the managers and their staff in public-sector mental health programs will be necessary to address the challenges of workforce development and evidence-based practice implementation.

Conclusions Although leadership functions may vary by organizational level or disci- pline (70,71), the study presented here suggests that the supervisor-su- pervisee dyad is a potentially impor- tant point of influence in affecting attitudes toward adopting evidence- based practice. However, in order to change attitudes and practice, lead- ers must persevere in the change process, and multiple hurdles to change should be expected and al- lowed for (72–76).

Behavioral health services organi- zations often deal with change as a

PSYCHIATRIC SERVICES ♦ ps.psychiatryonline.org ♦ August 2006 Vol. 57 No. 8 11116677

aar.qxd 7/20/2006 10:01 AM Page 1167

function of internal initiatives or in response to external demands. Lead- ers at different organizational levels often spearhead or manage such changes. Although this study deals with attitudes toward evidence-based practice, it also relates to organiza- tional change in general. Organiza- tional context, individual provider differences, and type and complexity of the evidence-based practice to be implemented must all be considered (77). Leadership at the supervisor- supervisee level is important in man- agement of change, as this is a fre- quent point of contact, influence, and shared meaning in organizations. Because of the complexity of organi- zations, providers, and clients, there is no single factor or correct ap- proach for implementation of evi- dence-based practices in behavioral health service organizations. Howev- er, the study presented here provides some guidance in improving our un- derstanding of how leadership may influence providers’ attitudes. The link between attitudes and actual im- plementation of evidence-based practices has yet to be confirmed, however.

This study adds to the evidence that leadership is one factor that can affect the implementation of evi- dence-based practices in behavioral health services. This study provides additional evidence that multiple fac- tors in the service context are impor- tant in understanding attitudes to- ward evidence-based practice (4,6,7, 75,78). Leadership geared toward promoting adoption of innovation and change is critical to the success of implementing evidence-based prac- tices. Further work is needed to iden- tify who will benefit from improved leadership skills, how best to train and apply leadership skills, and when in the process of evidence-based practice implementation to provide training and development for effec- tive leadership.

Acknowledgments

This work was supported by grant MH- 001695 from the National Institute of Mental Health. The author thanks the program managers, supervisors, clini- cians, and case managers who participat- ed in this study.

References 1. Burns BJ: Children and evidence-based

practice. Psychiatric Clinics of North America 26:955–970, 2003

2. Goldman HH, Ganju V, Drake RE, et al: Policy implications for implementing evi- dence-based practices. Psychiatric Services 52:1591–1597, 2001

3. Essock SM, Goldman HH, Van Tosh L, et al: Evidence-based practices: setting the context and responding to concerns. Psy- chiatric Clinics of North America 26:919– 938, 2003

4. Glisson C: The organizational context of children’s mental health services. Clinical Child and Family Psychology Review 5:233–253, 2002

5. Ringeisen H, Hoagwood K: Clinical and re- search directions for the treatment and de- livery of children’s mental health services, in Handbook of Serious Emotional Distur- bance in Children and Adolescents. Edited by Marsh DT, Fristad MA. New York, Wi- ley, 2002

6. Aarons GA: Mental health provider atti- tudes toward adoption of evidence-based practice: the Evidence-Based Practice Atti- tude Scale (EBPAS). Mental Health Ser- vices Research 6:61–74, 2004

7. Aarons GA: Measuring provider attitudes toward evidence-based practice: organiza- tional context and individual differences. Child and Adolescent Psychiatric Clinics of North America 14:255–271, 2005

8. Rogers EM: Diffusion of Innovations. New York, Free Press, 1995

9. Corrigan PW, Garman AN: Transforma- tional and transactional leadership skills for mental health teams. Community Mental Health Journal 35:301–312, 1999

10. Corrigan PW, Lickey SE, Campion J, et al: Mental health team leadership and con- sumers’ satisfaction and quality of life. Psy- chiatric Services 51:781–785, 2000

11. Glisson C, Durick M: Predictors of job sat- isfaction and organizational commitment in human service organizations. Administra- tive Science Quarterly 33:61–81, 1988

12. Aarons GA, Woodbridge M, Carmazzi A: Examining leadership, organizational cli- mate and service quality in a children’s sys- tem of care, in The 15th Annual Research Conference Proceedings: A System of Care for Children’s Mental Health: Expanding the Research Base. Edited by Newman C, Liberton C, Kutash K, et al. Tampa, Uni- versity of South Florida, Louis de la Parte Florida Mental Health Institute, 2003

13. Avolio BJ, Bass BM, Jung DI: Re-examin- ing the components of transformational and transactional leadership using the Mul- tifactor Leadership Questionnaire. Journal of Occupational and Organizational Psy- chology 72:441–462, 1999

14. Garman AN, Davis-Lenane D, Corrigan PW: Factor structure of the transforma- tional leadership model in human service teams. Journal of Organizational Behavior 24:803–812, 2003

15. Bass BM: Does the transactional-transfor- mational leadership paradigm transcend

organizational and national boundaries? American Psychologist 52:130–139, 1997

16. Bass BM: Utility of managerial self-plan- ning on a simulated production task with replications in twelve countries. Journal of Applied Psychology 62:506–509, 1977

17. Bass BM: From transactional to transfor- mational leadership: learning to share the vision. Organizational Dynamics 18:19–31, 1990

18. Bass BM, Avolio BJ, Jung DI, et al: Pre- dicting unit performance by assessing transformational and transactional leader- ship. Journal of Applied Psychology 88:207–218, 2003

19. Bycio P, Hackett RD, Allen JS: Further as- sessments of Bass’s (1985) conceptualiza- tion of transactional and transformational leadership. Journal of Applied Psychology 80:468–478, 1995

20. Liao Z, Landry R: An empirical study on or- ganizational acceptance of new information systems in a commercial bank environ- ment, in Proceedings of the 33rd Hawaii International Conference on System Sci- ences. Los Alamitos, Calif, IEEE Comput- er Society Press, 2000

21. Hater JJ, Bass BM: Superiors’ evaluations and subordinates’ perceptions of transfor- mational and transactional leadership. Journal of Applied Psychology 73:695–702, 1988

22. Howell JM, Avolio BJ: Transformational leadership, transactional leadership, locus of control, and support for innovation: key predictors of consolidated-business-unit performance. Journal of Applied Psycholo- gy 78:891–902, 1993

23. Howell JM, Hall-Merenda KE: The ties that bind: the impact of leader-member ex- change, transformational and transactional leadership, and distance on predicting fol- lower performance. Journal of Applied Psy- chology 84:680–694, 1999

24. Judge TA, Piccolo RF: Transformational and transactional leadership: a meta-analyt- ic test of their relative validity. Journal of Applied Psychology 89:755–768, 2004

25. Pearce CL, Sims HP: Vertical versus shared leadership as predictors of the effectiveness of change management teams: an examina- tion of aversive, directive, transactional, transformational, and empowering leader behaviors. Group Dynamics: Theory, Re- search, and Practice 6:172–197, 2002

26. Vandenberghe C, Stordeur S, D’hoore W: Transactional and transformational leader- ship in nursing: structural validity and sub- stantive relationships. European Journal of Psychological Assessment 18:16–29, 2002

27. Lowe KB, Kroeck KG, Sivasubramaniam N: Effectiveness correlates of transforma- tional and transactional leadership: a meta- analytic review of the MLQ literature. Leadership Quarterly 7:385–425, 1996

28. Dakof GA, Tejeda M, Liddle HA: Predic- tors of engagement in adolescent drug abuse treatment. Journal of the American Academy of Child and Adolescent Psychia- try 40:274–281, 2001

29. Ehrhart MG, Naumann SE: Organizational citizenship behavior in work groups: a

PSYCHIATRIC SERVICES ♦ ps.psychiatryonline.org ♦ August 2006 Vol. 57 No. 811116688

aar.qxd 7/20/2006 10:01 AM Page 1168

PSYCHIATRIC SERVICES ♦ ps.psychiatryonline.org ♦ August 2006 Vol. 57 No. 8 11116699

group norms approach. Journal of Applied Psychology 89:960–974, 2004

30. Tejeda MJ, Scandura Ta, Pillai R: The MLQ revisited: psychometric properties and recommendations. Leadership Quar- terly 12:31–52, 2001

31. Howell JM: Organization contexts, charis- matic and exchange leadership, in KLSP: Transformational Leadership, Working Pa- per. College Park, Md, Academy of Leader- ship Press, 1997

32. House RJ, Spangler WD, Woycke J: Per- sonality and charisma in the US presidency: a psychological theory of leader effective- ness. Administrative Science Quarterly 36:364–396, 1991

33. Howell JM, Frost PJ: A laboratory study of charismatic leadership. Organizational Be- havior and Human Decision Processes 43:243–269, 1989

34. Priestland A, Hanig R: Developing first- level leaders. Harvard Business Review 83:112–120, 2005

35. Gardner WL, Avolio BJ: The charismatic relationship: a dramaturgical perspective. Academy of Management Review 23:32– 58, 1998

36. Bass BM, Avolio BJ: The implications of transformational and transactional leader- ship for individual, team, and organization- al development, in Research in Organiza- tional Change and Development. Green- wich, Conn, JAI, 1990

37. Hollander E: Leadership Dynamics. New York, Free Press, 1978

38. House RJ: A path-goal theory of leadership effectiveness. Administrative Science Quar- terly 16:321–328, 1971

39. Jung DI: Transformational and transaction- al leadership and their effects on creativity in groups. Creativity Research Journal 13:185–195, 2001

40. Waldman DA, Bass BM, Yammarino FJ: Adding to contingent-reward behavior: the augmenting effect of charismatic leader- ship. Group and Organization Studies 15:381–394, 1990

41. Avolio BJ, Bass BM: Transformational lead- ership, charisma, and beyond, in Emerging Leadership Vistas. International Leader- ship Symposia Series. Edited by Hunt JG, Baliga BR. Lexington, Mass, Lexington Books, 1988

42. Evans MG: Extensions of a path-goal theo- ry of motivation. Journal of Applied Psy- chology 59:172–178, 1974

43. House RJ, Mitchell T: Path-goal theory of leadership. Journal of Contemporary Busi- ness 5:81–97, 1974

44. Amabile TM: How to kill creativity. Har- vard Business Review 76:76–88, 1998

45. Gotham HJ: Diffusion of mental health and substance abuse treatments: development, dissemination, and implementation. Clini- cal Psychology: Science and Practice 11:161–176, 2004

46. Zaltman G, Duncan R, Holbek J: Innova- tions and Organizations. New York, Wiley,

1973

47. Zmud RW: Design alternatives for organiz- ing information systems activities. MIS Quarterly 8:79–93, 1984

48. Aarons GA, Carmazzi A: Organizational culture and climate and mental health provider attitudes toward evidence-based practice. Psychological Services 3:61–72, 2006

49. Loy JW: Sociopsychological attributes asso- ciated with the early adoption of a sport in- novation. Journal of Psychology 70:141– 147, 1968

50. Ogborne AC, Wild TC, Braun K, et al: Measuring treatment process beliefs among staff of specialized addiction treat- ment services. Journal of Substance Abuse Treatment 15:301–312, 1998

51. Garland AF, Kruse M, Aarons GA: Clini- cians and outcome measurement: what’s the use? Journal of Behavioral Health Ser- vices and Research 30:393–405, 2003

52. Bass B, Avolio B: MLQ: Multifactor Lead- ership Questionnaire (Technical Report). Binghamton, NY, Binghamton University, Center for Leadership Studies, 1995

53. Hedeker DR, Gibbons RD, Davis JM: Ran- dom regression models for multicenter clinical trials data. Psychopharmacology Bulletin 27:73–77, 1991

54. Raudenbush SW, Bryk AS: Hierarchical Linear Models: Applications and Data Analysis Methods. Thousand Oaks, Calif, Sage, 2002

55. Snijders T, Bosker R: Multilevel Analysis: An Introduction to Basic and Advanced Multilevel Modeling. London, Sage, 1999

56. Muthén LK, Muthén BO: Mplus User’s Guide. Los Angeles, Muthén and Muthén, 1998

57. Damanpour F: Organizational innovation: a meta-analysis of effects of determinants and moderators. Academy of Management Journal 34:555–590, 1991

58. Frambach RT, Schillewaert N: Organiza- tional innovation adoption: a multi-level framework of determinants and opportuni- ties for future research. Journal of Business Research: Special Issue: Marketing Theory in the Next Millennium 55:163–176, 2002

59. Denton GD, Smith J, Faust J, et al: Com- paring the efficacy of staff versus housestaff instruction in an intervention to improve hypertension management. Academic Medicine 76:1257–1260, 2001

60. Cohen L, Sargent M, Sechrest L: Use of psychotherapy research by professional psychologists. American Psychologist 41: 198–206, 1986

61. Morrow-Bradley C, Elliott R: Utilization of psychotherapy research by practicing psy- chotherapists. American Psychologist 41: 188–197, 1986

62. Igbaria M, Guimaraes T: Exploring differ- ences in employee turnover intentions and its determinants among telecommuters and non-telecommuters. Journal of Manage- ment Information Systems 16:147–164, 1999

63. Fischer EP, Shumway M, Owen RR: Prior- ities of consumers, providers, and family members in the treatment of schizophre- nia. Psychiatric Services 53:724–729, 2002

64. Meehan T, Bergen H, Stedman T: Monitor- ing consumer satisfaction with inpatient service delivery: the inpatient evaluation of service questionnaire. Australian and New Zealand Journal of Psychiatry 36:807–811, 2002

65. Hackman MZ, Furniss AH, Hills MJ, et al: Perceptions of gender-role characteristics and transformational and transactional leadership behaviours. Perceptual and Mo- tor Skills 75:311–319, 1992

66. Carless SA: Gender differences in transfor- mational leadership: an examination of su- perior, leader, and subordinate perspec- tives. Sex Roles 39:887–902, 1998

67. Barriere MT, Anson BR, Ording RS, et al: Culture transformation in a health care or- ganization: a process for building adaptive capabilities through leadership develop- ment. Consulting Psychology Journal: Prac- tice and Research 54:116–130, 2002

68. Power AK: Achieving the promise through workforce transformation: a view from the Center for Mental Health Services. Admin- istration and Policy in Mental Health 32:489–495, 2005

69. Hogan MF: The President’s New Freedom Commission: recommendations to trans- form mental health care in America. Psy- chiatric Services 54:1467–1474, 2003

70. Harrison T, Gray AJ: Leadership, complex- ity and the mental health professional: a re- port on some approaches to leadership training. Journal of Mental Health (UK) 12:153–159, 2003

71. Reed J: Leadership in the mental health service: what role for doctors? Psychiatric Bulletin 19:67–72, 1995

72. Aveline MO: Principles of leadership in brief training groups for mental health care professionals. International Journal of Group Psychotherapy 43:107–129, 1993

73. Byalin K: Managing to win: front-line lead- ership in public mental health settings. Ad- ministration and Policy in Mental Health 16:191–199, 1989

74. Cook JV: Innovation and leadership in a mental health facility. American Journal of Occupational Therapy 49:595–606, 1995

75. Corrigan PW, Steiner L, McCracken SG, et al: Strategies for disseminating evidence- based practices to staff who treat people with serious mental illness. Psychiatric Ser- vices 52:1598–1606, 2001

76. Yank GR, Barber JW, Spradlin WW: Men- tal health treatment teams and leadership: a systems model. Behavioral Science 39:293–310, 1994

77. Klein KJ, Sorra JS: The challenge of inno- vation implementation. Academy of Man- agement Review 21:1055–1080, 1996

78. Strupp HH, Anderson T: On the limitations of therapy manuals. Clinical Psychology: Science and Practice 4:76–82, 1997

aar.qxd 7/20/2006 10:01 AM Page 1169