Keeping Our ACT Together: The Role of Evidence-Based Supervision Strategies in Promoting a Resilient Assertive Community Treatment Workforce

Background and Purpose: Healthcare systems rely on their workforce to provide critical patient services even amidst unpredictable system shocks such as the COVID-19 pandemic. This was particularly true for Assertive Community Treatment (ACT) providers who continued delivering essential in-person services during the COVID-19 pandemic even as many outpatient providers shifted to remote work. Resilience scholarship suggests promotive factors – such as shared team identity, ongoing support and trust, and shared leadership – may reduce provider burnout and turnover by supporting providers’ navigation of systemic stressors. However, these propositions have not been tested in intensive outpatient mental health services. The purpose of this study was to examine associations among theorized supervisory promotive factors and ACT team provider resilience, operationalized as level of burnout and turnover intention, amidst the extraordinary system stressor of the COVID-19 pandemic.

Methods: ACT providers working on 81 teams in four states in the USA completed a web-based survey in 2021 that asked providers about their intention to leave their current position within the next 6 months, quality of their supervisory working alliance, experience in direct clinical supervision, characteristics of their team and team leader, and individual characteristics. Validated and reliable measures were used for constructs including the intent to leave scale, maslach’s burnout scale, brief supervisory working alliance scale, transformational leadership subscale of the multifactor leadership questionnaire, and the evidence-based clinical supervision scale. Primary outcomes were intent to leave and supervisory working alliance. Multilevel mixed effects models tested the associations between each group of predictors and the two primary outcomes before testing a fully saturated model.

Results: A total of N=335 ACT providers on 81 teams in 4 States responded to the survey yielding a response rate of 50%. The majority of participants identified as female (82%) and White (80%) and had three years or less of tenure with their teams (74%). Providers who experienced higher levels of empirically-supported leadership and supervision strategies reported significantly better supervisory working alliances (b=.454, p<.001). Higher supervisory alliance ratings were significantly associated with reduced intent to leave (b=-1.074, p<.001) and reduced depersonalization of clients (b=-.141, p<.001).

Conclusions and Implications: Supervision and leadership strategies have a significant influence on factors that are critical for team resilience, staff retention, and patient care. Supervisory alliances were stronger when accompanied by empirically supported supervision strategies that promote skill and knowledge development. More than being emotionally supportive, supervisors who successfully translate expertise to supervisees have stronger relationships and may be more likely to retain behavioral health providers. Shifting our focus from individual resilience factors to team level resilience promotion illuminates a potential pathway to further resilience promotion for essential workers. These findings fill a gap in our understanding of actionable strategies ACT team leaders can use to fortify their teams and supervisees against external shocks that contribute to turnover while providing essential healthcare to people living with serious mental illness.