Dr. Aarons is affiliated with the Child and Adolescent Services Research Center, 3020 Children’s Way, MC-5033, San Diego, CA 92123 [e-mail: ude.dscu@snoraag]. He is also with the Department of Psychiatry, University of California, San Diego.
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Abstract
Objective
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 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 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. 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’ 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.
Conclusions
Mental health service organizations may benefit from improving transformational and transactional supervisory leadership skills in preparation for implementing evidence-based practices.
There is growing momentum and pressure to move evidence-based mental health interventions into real-world practice settings [1–5]. Most of these practice settings involve a relationship between a clinical or case management supervisor and practitioners who provide 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 activities. Recent work has also demonstrated that mental health service providers’ attitudes toward adopting evidence-based practice are associated with organizational context [for example, structure and policies] and individual provider differences [for example, education and experience] [6,7]. Yet, although leadership is held to influence the adoption of innovations, such as evidence-based practices [8], there has been little research on the association between leadership of the mental health supervisor and staff attitudes toward adopting evidence-based practice. However, some more general leadership studies have been conducted.
Leadership research is pervasive in the organizational literature, and studies in mental health services suggest 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 positive leadership in human service organizations were associated with higher levels of organizational commitment. In a study on mental health services for youths, organizational climate 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 leadership, organizational and clinical process, and consumer satisfaction and outcome. However, research is needed that examines the effect of leadership on attitudes toward adopting evidence-based practices in mental health service settings.
Transformational and transactional leadership are two well-studied leadership styles that have been assessed by the Multifactor Leadership Questionnaire [MLQ] [9,13,14]. Transformational and transactional leadership span both cultural and organizational boundaries [15] and have been assessed and validated in numerous studies [16–26]. Leadership studies with the MLQ have also been conducted 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 transformational and transactional leadership. The styles are not mutually exclusive, 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 supervisory 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 functional proximity to supervisees in an organizational setting. Transformational leadership is thought to increase the follower’s intrinsic motivation [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 followers are rewarded for meeting specific goals or performance criteria [37–40]. Rewards and positive reinforcement are provided or mediated by the leader. Thus transactional leadership is more practical in nature because of its emphasis on meeting specific targets or objectives [41–43]. An effective transactional leader is able to recognize and reward followers’ accomplishments in a timely way. However, subordinates of transactional leaders are not necessarily expected to think innovatively and may be monitored on the basis of predetermined criteria. Poor transactional leaders may be less likely to anticipate problems and to intervene before problems come to the fore, whereas more effective transactional leaders take appropriate action in a timely manner [39].
A transactional leadership style is appropriate in many settings and may support adherence to practice standards but not necessarily openness to innovation. A transformational leadership style creates a vision and inspires subordinates to strive beyond required expectations, whereas transactional leadership focuses more on extrinsic motivation for the performance of job tasks [39,44]. Thus it is likely that transformational leadership would influence attitudes by inspiring acceptance of innovation through the development of enthusiasm, trust, and openness, whereas transactional leadership would lead to acceptance of innovation through reinforcement and reward.
In summary, leadership is important to consider in relation to acceptance of innovations and to work attitudes, perceptions, behavior, service quality, and client outcomes. Because leadership is associated with organizational and staff performance, we propose that it is likely to influence mental health providers’ attitudes toward adoption of evidence-based practices. Although leadership is prominent in our model of implementation of evidence-based practices [7], few studies have examined transformational and transactional leadership and mental health providers’ attitudes. Finally, no studies have examined leadership and attitudes toward adopting evidence-based practices in mental health services for youths.
In understanding organizational predictors of attitudes toward evidence-based practices, it is also important to consider and control for individual-level variables, such as providers’ demographic characteristics. A recent review suggests that demographic characteristics and attitudes can be influential in the willingness to adopt and implement an innovation [45]. For example, receptivity to change can be an important determinant of innovation success [46,47]. Rogers [8] asserted that having more formal education, as well as favorable attitudes toward change and science, are associated with increased adoption of an innovation. Educational attainment is positively associated with endorsement of evidence-based treatment services, adoption of innovations, and attitudes toward adoption of evidence-based practices [6,48–50]. In specialty mental health clinics, compared with professional providers, interns report having a more positive attitude toward using evidence-based assessment protocols [51] and toward adopting evidence-based practices [6]. Because there is a link between organizational characteristics, individual differences, and attitudes toward work, these factors should be included in studies of attitudes toward evidence-based practice.
The purpose of the study presented here was to examine the association of transformational and transactional supervisor leadership with service providers’ attitudes toward evidence-based practices. We hypothesized that more positive transformational leadership would be associated with more positive attitudes toward implementing evidence-based practices, as evidenced by greater openness, greater sense of appeal of evidence-based practices, and lower perceived divergence of usual practice with evidence-based practices. We also hypothesized that transactional leadership would be associated with more positive attitudes toward adopting evidence-based practice, 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 affecting the provision of mental health services to children, adolescents, and their families in San Diego County, California [6]. Organizational and individual participation rates were high [94 and 96 percent, respectively]. Data were collected between November 21, 2000, and September 19, 2001. Of the 322 providers in the larger study, 19 participants [5.9 percent] 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 characteristics for individual-level nominal and continuous variables in the study. A total of 245 respondents [81 percent] were full-time employees. Primary disciplines included marriage and family therapy [103 participants, or 34 percent], social work [99 participants, or 33 percent], psychology [65 participants, or 21 percent], psychiatry [five participants, or 2 percent], and “other” [for example, criminology, 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 respondents was 35.7±10.5 years. Seventy-six percent were female. Sixty-five percent were Caucasian, 15 percent 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. [Percentages total more than 100 percent because of rounding.]
Table 1
Characteristics of 303 providers working in 49 publicly funded mental health programs for youths
VariableN%Gender Male7123 Female23277Staff Professional22474 Intern7926Education level Some college103 Bachelor’s degree5719 Some graduate school3211 Master’s degree17558 Doctoral degree289Race or ethnicity Caucasian19765 Latino4415 African American207 Asian or Pacific Islander196 Native American21 Other217Age [M±SD]35.7±10.49Job tenure [M±SD years]1.97±3.17
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Measures
Provider survey
The provider survey incorporated questions about providers’ demographic characteristics, including age, sex, education level, professional status [intern or professional], and job tenure [time working in the present employment setting] [6]. Providers’ education level was assessed with ordered categories from low to high: attainment of some college, 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 employed professional. Professional status was coded as 0 for staff and as 1 for interns.
Attitudes toward evidence-based practice
The Evidence-Based Practice Attitude Scale [EBPAS] [6] was used to assess mental health providers’ attitudes toward evidence-based practice. 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 derived 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, supervisor, or state. The score on the openness 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 divergence subscale assesses the extent to which the provider perceives evidence-based practices as not clinically useful and less important than clinical experience. The total score on the EBPAS represents one’s global attitude toward adoption of evidence-based practices. The overall Cronbach’s alpha reliability for the EBPAS was good [α=.77], and subscale alphas ranged from.90 to.59. The EBPAS validity is supported by associations 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, ranging 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]. Transformational leadership was assessed with four subscales of idealized influence [eight items, α=.87], inspirational motivation [four items, α=.91], intellectual 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 passive management by exception [four items, α=.82]. Providers were asked to judge the extent to which their immediate supervisor engaged in specific 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 described to him or her in detail. Permission 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 assistant administered providers’ surveys and was available during the survey session to answer any questions that arose. A few surveys were left for completion for providers who did not attend the survey sessions. Such surveys were either mailed back in a prepaid envelope or picked up by a research assistant. Participants received a verbal and written description of the study, and informed consent was obtained before the survey. Participation in the study was voluntary, and all participant responses were confidential. This study was approved by the appropriate institutional review boards.
Analyses
Pearson product-moment correlation analyses were first conducted to examine associations of transformational and transactional leadership and individual-level covariates with the dependent variables—that is, EBPAS scores representing attitudes toward evidence-based practices. Next, regression 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 providers were nested within mental health programs, resulting in potential 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 significance 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 positive attitudes toward evidence-based practice. Specifically, transformational leadership was significantly positively associated with scores on the EBPAS subscales of appeal, openness, 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 regression analysis was performed for each EBPAS subscale and one for the overall scale.
Table 2
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
VariableAgeSexEduca TionInternJob tenureTransform Ational leadershipTransac tional leadershipAppealOpen nessRequire mentsDiver genceAgeSex−.186***Education.383*.037Intern−.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*.109Openness−.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***
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*p