The authors noted a significant gap between evidence-based practice (EBP) innovations and their adoption in the mental health care profession. 

[Fuller, B. E., Rieckmann, T., Nunes, E. V., Miller, M., Arfken, C., Edmundson, E., et al. (2007). Organizational readiness for change and opinions toward treatment innovations. Journal of Substance Abuse Treatment, 33(2), 183-192.]

Based on an in-depth review of implementation research, six core elements were identified as critical to adoption of and maintaining EBP programs:

1.  selection of staff capable of implementing such programs;
2.  staff training;
3.  on-going coaching;
4.  supervision and assessment measures to provide staff performance feedback;
5.  program evaluation;
6.  fostering of implementation/maintenance via administrative supports (Fixsen, Naoom, Blasé, Friedman & Wallace, 2005). 

They assessed the utility of the Organizational Readiness for Change (ORC) scale (Lehman, Greener & Simpson, 2002) using a regression model on four types of EBP: 

• manuals,
• medication,
• integrated mental health services, and
• motivational enhancements. -

They also provided a literature review of these four EBP types.

Research Design Method

Three interrelated self-report surveys focusing on organizational, treatment unit, and workforce issues were utilized and completed sequentially.  Opinion items were measured on a five-point Likert scale.  Complete details on collection methods are provided in other literature (McCarty, Fuller, Arfen, Miller, Nunes, Edmundson, et al, 2007). Surveys were completed online or via paper transmission.  The workforce survey was distributed via sealed correspondence to specified employees, and, most often, distributed and completed during staff meetings.

The Oregon Health & Science University Institutional Review Board (IRB) reviewed and approved study procedures, and 40 IRBs reviewed and approved the protocol.  Respondent participation could be declined. 

Items for the organizational self-report survey included information on ownership status, primary service setting, and company size. Response rate was 95%. Information in the treatment unit survey covered care and service levels, facility accreditation and licensure, patient characteristics, revenue sources, staffing, staff retention, and scales assessing treatment environment and philosophy.  A response rate of 91% was reported.

The workforce survey assessed such items as training, credentials, education, years of experience, and opinions toward specific treatment types.  It also included the 115-item ORC scale (Lehman, Greener & Simpson, 2002) which assesses factors influencing organizational change.  Four categories covering 18 topics were addressed:

• Motivation for change based on three factors -- program need for improvement, perceived training needs and pressure to change;
• institutional resources measured five areas covering adequacy of resources - office space, staffing, training resources, computer access; and e-mail/Internet useage;
• staff attributes influencing organizational change - professional growth potential, counseling efficacy, influence on co-workers, and adaptability;
• organizational climate, which included six topics -- agency mission and goal clarity; staff cohesion; staff autonomy; management openness to staff communication; perception of stress level; and openness to change.

 A response rate of 71% was reported for the workforce survey.

An ORC scale initial validation study indicated that the 18 topics were generally single factors and that the psychometric properties were strong (Lehman, et al., 2002).      

Sample Population

The National Drug Abuse Treatment Clinical Trials Network (CTN) includes 17 regional research centers and approximately 150 community-based groups which provide AOD treatment services, and whose membership fluctuates over time as protocols dictate.  The network was founded to provide support for innovations in EBP and evidence about efficacy of those practices.  The sample population included:

• participants from 249 treatment units in this network including
• outpatient treatment programs (n = 79)
• residential and inpatient programs (n = 95)
• detoxification programs (n = 34) and
• methadone programs (n = 41)
• Treatment units with at least five staff members were required to allow for the use of models using group mean centering
• Respondents included administrators and staff   

Measurements

Factor analysis was used on opinion items to form factor scores.  Hierarchical linear modeling assessed the influence of organizational characteristics and ORC domains on factor scores. (Comprehensive details of the methods and results are provided in the full journal article.) Five factor scores were generated and modeled as the outcome variable in a bi-level random effects regression model. The five score categories are:

1.  EBP and manualized treatment;
2.  Confrontation and non-compliance discharge;
3.  medications;
4.  mental health services;
5.  motivational incentives. 

Level 1 predictors were the ORC scales centered on the group mean to note within-group variation.  Level 2 predictors included eight organizational variables: 1) independent treatment centers; 2) for-profit status; 3) annual revenue; 4) national accreditation; 5) residential treatment centers; 6) outpatient treatment services; 7) methadone services; 8) detoxification centers. The algebraic framework of the random-effects mixed model is provided in this article.   

Findings 

• A large and heterogeneous population for assessing the influence of the ORC scales in EBP was provided by the CTN.
• Staff attributes appeared to have positive and negative effects with regard to EBP.
• Within the ORC domains, perceived need for improvement was key to motivation for change, and staff members scoring high here also endorsed treatment manuals, medications and motivational incentives.
• Staff internet access surfaced as a significant institutional resource.
• Staff who rated internet access as adequate showed more support for treatment manuals, medications and motivational incentives and less support for confrontation and non-compliance discharge.
• Staff who rated themselves as more influential with peers indicated more support of manuals, integrated mental health services and motivational incentives.
• Staff indicating less influence with peers appeared more supportive of confrontation and non-compliance discharge.
• Perception of opportunities for professional growth affected positively willingness to use medications, and negatively influenced the use of confrontation and non-compliance discharge. 
  

Organizational climate measures were also rated influential:

• Perceived stress ratings were lower when support for using confrontation and non-compliance discharges was evidenced.
• Stress ratings were higher with more support for integrated mental health services - apparently reflecting change and integration pressures. 
• A strong sense of mission clarity was also associated with use of treatment manuals and integrated mental health services.

The authors note that many of the 13,000+ specialty treatment centers for drug and alcohol abuse in the U.S. are under pressure to improve economic efficiency while providing EBP-proven treatment. Analysis of organizational and workforce variables added to the validity of the ORC, and indicate that the ORC measures important factors in organizational readiness for change. The analysis of the ORC dimensions within the CTN indicates that treatment center leaders should systematically involve their staff in the change process. The authors recommend subsequent examination of ORC influence on patient outcomes and program performance in clinical trials. 

Tools/Knowledge Objects/Resources/Contacts:

• Lehman, W. E. K., Greener, J. M., & Simpson, D. D. (2002). Assessing organizational readiness for change. Journal of Substance Abuse Treatment, 22, 197-209.
• McCarty, D., Fuller, B., Arfken, C. L., Miller, M., Nunes, E. V., & Edmundson, E. (2007). Direct care workers in the National Drug Abuse Treatment Clinical Trials Network: Characteristics, opinion, and beliefs. Psychiatric Services, 58, 181-190.