Technical and Social Influences On Frontline Practice: Do Cohesive Organizational Environments Hinder Change?

Background: Efforts to promote the implementation of evidence-based practices in challenging human services settings are advancing, but we still have much to learn. Some important remaining implementation questions relate to the practices of frontline staff within organizational contexts. This is especially true in routine substance abuse settings where traditional organizational norms can affect practitioners' inclinations and capacities to apply an evidence-based treatment approach (Miller et al., 2006). Helpful insights related to the implementation of evidence-supported practices have been derived from the work of Everett Rogers (2003). Rogers' theories, however, were based primarily on individual entrepreneurs rather than staff who work in highly regulated organizations. Hence, in addition to Rogers' insights about the motives and inclinations of frontline practitioners, a science of implementation in human services must address organizational context. Two aspects of organizational context that are emerging as influential in the implementation process include the degree of cohesiveness among staff (Glisson, 2007) and an organization's orientation toward change (Simpson, 2009). This study extends current work addressing the relationship between organizational contexts and the use of evidence-based practices in outpatient substance abuse treatment.

Methods: The study data come from a cross-sectional survey of counselors who provide outpatient substance abuse treatment. Counselors were selected via a nested probability sample. Fifty-seven (81%) organizations and 293 (68%) counselors participated. Treatment approaches were measured with a scale adapted from the Practitioner Technique Inventory (Ball, et al., 2002). Organizational contexts were measured with scales designed to assess specific dimensions of organizational climate and culture (UT-CMHSRC, 2002; TCU-SOF, 2005). Organizations were first classified according to the dimensions of organizational cohesiveness and orientation to change. ANOVA and random effects multi-level (HLM) models were conducted to appropriately address the nested sample and assess associations between organizational contexts and frontline practice.

Results: ANOVA models indicate that levels of evidence-based treatment practices are highest in change-oriented organizational contexts. The use of evidence-based treatment practices is lowest in diffuse and traditional organizational contexts. By contrast, directive/12-step treatment techniques are used most extensively in cohesive organizational contexts, whether change-oriented or not. Cross-level HLM results indicate that change-oriented organizational contexts may promote the use of evidence-based techniques as they enhance practitioners' capacity to use training. Also, a cross-level HLM interaction model indicates that practitioners feel more positively about their organizations when they are freer to use traditional treatment techniques.

Conclusions and Implications: Findings from this study are consistent with the observation that the implementation of evidence-supported practices is associated with both social and technical processes in organizations (Glisson, et al., 2008). The influences of technical processes associated with change-oriented contexts and leadership have become clearer, and are again supported in this study's findings. The influences of social processes, such as co-worker cohesion, however, clearly warrant further attention. When cohesive staff bond together in their use of traditional practices, as seems the case in many substance abuse treatment settings, successful efforts at innovation implementation are likely to be those that can address and creatively capitalize on the social aspects of work in challenging organizational contexts.